American Heart Association Stats 2005 Update

H artt Disease
Hea isea e aand

d
Stroke
S ok Stat
Statistics
ic —
20055 Update
a
Our guide to current statistics and

the supplement to our "Heart and Stroke Facts"
Statistical Fact Sheets
Information for the population groups and risk factors listed below is available at americanheart.org. Click on “Publications
& Resources,” then “Statistics,” then “Statistical Fact Sheets.”
Populations
African Americans and Cardiovascular Diseases — Statistics
American Indians or Alaska Natives and Cardiovascular Diseases — Statistics
Asian or Pacific Islanders and Cardiovascular Diseases — Statistics
Baby Boomers and Cardiovascular Diseases — Statistics
Hispanics or Latinos and Cardiovascular Diseases — Statistics
International Cardiovascular Disease Statistics [includes death rates by country]
Men and Cardiovascular Diseases — Statistics
Older Americans and Cardiovascular Diseases — Statistics
Whites and Cardiovascular Diseases — Statistics
Women and Cardiovascular Diseases — Statistics
Youth and Cardiovascular Diseases — Statistics
Risk Factors
Diabetes Mellitus — Statistics
High Blood Cholesterol and Other Lipids — Statistics
High Blood Pressure — Statistics
Metabolic Syndrome — Statistics
Overweight and Obesity — Statistics
Physical Inactivity — Statistics
Tobacco — Statistics
Miscellaneous
Cardiovascular Procedures — Statistics
Congenital Cardiovascular Defects — Statistics
Death Rates by State — Statistics
Hospital Discharges for Cardiovascular Diseases — Statistics
Leading Causes of Death — Statistics
Nutrition and Cardiovascular Diseases — Statistics
Out-of-Hospital Cardiac Deaths by State — Statistics
Peripheral Arterial Disease — Statistics
Sudden Deaths From Cardiac Arrest — Statistics
(Throughout this publication, statistics relating to sudden death from cardiac arrest are highlighted in pink.)
Understanding and Using American Heart Association Statistics
Venous Thromboembolism — Statistics
Check Our Web Sites

For more information on cardiovascular diseases including stroke, see americanheart.org and StrokeAssociation.org.
1a Heart Disease and Stroke Statistics — 2005 Update, American Heart Association
Table of Contents
1)
2)
3)
Statistical Highlights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coronary Heart Disease, Acute Coronary Syndrome and Angina
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Pectoris .
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10
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4) Stroke and Stroke in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
5) High Blood Pressure (and End-Stage Renal Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
6) Congenital Cardiovascular Defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
7) Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
8) Other Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Arrhythmias (Disorders of Heart Rhythm) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Arteries, Diseases of (including Peripheral Arterial Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Bacterial Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Rheumatic Fever/Rheumatic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Valvular Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Venous Thromboembolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
9) Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
High Blood Cholesterol and Other Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Physical Inactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
10) Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
11) Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
12) Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
13) Medical Procedures and Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
14) Economic Cost of Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
15) At-a-Glance Summary Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Men and Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Women and Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Ethnic Groups and Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Children, Youth and Cardiovascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
16) Glossary and Abbreviation Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
About These Statistics

All statistics are for the most recent year available. Prevalence, mortality and hospitalizations are computed for 2002 unless
otherwise noted. Incidence estimates come from specific studies and remain the same until new studies become available.
“Total mention mortality” is for 2001. Economic costs are for 2005. Due to late release of mortality data, some mortality are
not updated to 2002. U.S. and state death rates and prevalence rates are age-adjusted (unless otherwise specified) per
100,000 population using the 2000 U.S. standard as the base.
Do not compare the prevalence or incidence statistics with those in past issues of this publication. It can lead to serious
misinterpretation of time trends.
If you have questions about statistics or any points made in this booklet, please contact the Biostatistics Program Coordinator
at the National Center, Nancy.Haase@heart.org, 214-706-1423. Direct media inquiries to News Media Relations at
inquiries@heart.org or 214-706-1173.
We do our utmost to ensure that this booklet is error-free. If we discover errors after publication, we’ll provide corrections at
our Web site, americanheart.org. Click on “Publications & Resources,” then “Statistics,” then “Heart Disease and Stroke
Statistics — 2005 Update.”
Acknowledgement
We would like to thank the members of the Council on Epidemiology and Prevention’s Committee on Statistics and the
Stroke Statistics Subcommittee for their contributions to this publication.
Suggested Citation
American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Texas.: American Heart Association; 2005.
©2005, American Heart Association.
Heart Disease and Stroke Statistics — 2005 Update, American Heart Association 1
1 Statistical Highlights
Overweight and Obesity Stroke

Now commonly described as modern epidemics, overweight and About 700,000 Americans will have a stroke this year — that’s
obesity together represent the No. 2 preventable cause of death in someone every 45 seconds. Stroke is our nation’s No. 3 killer and
the United States, second only to cigarette smoking. Today, nearly a leading cause of severe, long-term disability. Some population
seven of every 10 U.S. adults are overweight, and about three of groups, including African Americans, American Indians or Alaska
every 10 are obese. And among children, overweight and obesity Natives, and Mexican Americans, have a higher than average risk.
are also rising at an alarming rate. Recent studies also indicate that the risk of stroke may be higher
in women during pregnancy and the six weeks following
• Since 1991, the prevalence of obesity has increased 75
childbirth.
percent.
• Obesity has increased among every ethnic group. For more information on stroke, see page 16.
• The estimated annual cost of obesity-related diseases in the
United States is about $100 billion. Children and Cardiovascular
For more information on overweight and obesity, see page 39. Disease
CVD ranks as the No. 2 cause of death (behind certain accidents)
Physical Inactivity for children under age 15. And in 2002 about 210,000
cardiovascular procedures were performed on people age 15 or
Physical inactivity, a risk factor for cardiovascular disease
younger.
(CVD), is becoming increasingly prevalent. More than ever,
Americans are turning down or missing out on important Thousands of babies are born each year with congenital
opportunities to stay in shape. And while our level of activity cardiovascular defects. These defects claim more lives than any
declines, our rates of heart disease increase. other kind of congenital defects — about 2,200 lives a year of
children under age 15. About 1 million Americans alive today
• 38.6 percent of United States adults report no leisure-time
have congenital cardiovascular defects — and about 25 percent
physical activity.
are children.
• The relative risk of coronary heart disease associated with
physical inactivity ranges from 1.5 to 2.4, which is Most CVD in children is due to congenital cardiovascular
comparable to high blood cholesterol, high blood pressure or malformations. However, more and more children are also
cigarette smoking. developing many preventable risk factors for cardiovascular
diseases — such as high blood pressure (page 21), smoking
For more information on physical inactivity, see page 37.
(page 32), high blood cholesterol (page 35), physical inactivity
(page 37), overweight (page 39), and the metabolic syndrome
Women and Cardiovascular (page 44).
Disease For more information on congenital cardiovascular defects, see
page 24.
According to an American Heart Association survey, only 13
percent of women consider CVD their greatest health risk. But
statistics show that no disease, not even cancer, claims as many
women’s lives as CVD. It causes about a death a minute among
females —nearly half a million female lives every year. That’s
more lives than are claimed by the next six causes of death
combined.
Information on women and cardiovascular disease is included
throughout this publication.
2 Heart Disease and Stroke Statistics — 2005 Update, American Heart Association
Cardiovascular Diseases 2
(ICD/9 390–459, 745–747) (ICD/10 I00–I99, Q20–Q28;
see Glossary for details and definitions)
• Congestive heart failure — 4,900,000.

Hospital
Population Prevalence Mortality Discharges Cost • Stroke —5,400,000.
Group 2002 2002# 2002 2005 • Congenital cardiovascular defects — 1,000,000.
Total population 70,100,000 927,448 6,373,000 $393.5 billion (Unpublished NHIS survey data, 1993–95, CDC/NCHS)
(34.2%)
• 1 in 4 males and females has some form of CVD.
Total males 32,500,000 433,825 3,209,000 — (NHANES 2001–02, CDC/NCHS)
(34.4%) (46.8%)*
Total females 37,600,000 493,623 3,164,000 —
• The following prevalences are for people age 18 and older:
(33.9%) (53.2%)* (NHIS [2001], CDC/NCHS, Vital and Health Statistics,
Series 10, No. 219, Feb. 2004)
White males 34.3% 375,392 — —
White females 32.4% 428,461 — — — Among whites only, 12.2 percent have heart disease,
Black males 41.1% 48,993 — — 20.1 percent have hypertension and 2.4 percent have had
Black females 44.7% 56,721 — — a stroke.
Mexican-American males 29.2% — — — — Among blacks or African Americans only, 9.6 percent
Mexican-American females 29.3% — — — have heart disease, 26.7 percent have hypertension and
2.9 percent have had a stroke.
Note: (—) = data not available. — Among Hispanics or Latinos, 6.1 percent have heart
* These percentages represent the portion of total mortality that is disease, 14.5 percent have hypertension and 1.8 percent
males vs. females. have had a stroke.
Sources: Prevalence: NHANES (1999–02), CDC/NCHS and — Among Asians, 5.4 percent have heart disease, 13.5 percent
NHLBI; data for white and black males and females are have hypertension and 2.2 percent have had a stroke.
for non-Hispanics. Total population data include children;
percentages for racial/ethnic groups are age-adjusted for — Among Native Hawaiians or other Pacific Islanders, 1.6
Americans age 20 and older.These data are based on self percent have heart disease, 14.5 percent have
reports. Mortality: CDC/NCHS; data for white and black hypertension and 6.3 percent have had a stroke.
males and females include Hispanics; data include congenital — Among American Indians or Alaska Natives, 12.6
cardiovascular disease. Hospital discharges: CDC/NCHS; percent have heart disease, 25.0 percent have
data include people both living and dead. Cost: NHLBI; hypertension and 1.1 percent have had a stroke.
data include direct and indirect costs for 2005.
# — Preliminary mortality.
Incidence
Prevalence • Based on the NHLBI’s Framingham Heart Study (FHS) in
its 44-year follow-up of participants and the 20-year follow-
Of the 70,100,000 Americans with one or more types of up of their offspring… (Hurst W. The Heart, Arteries and
cardiovascular disease (CVD), 27,000,000 are estimated to be age Veins. 10th ed. New York, NY: McGraw-Hill; 2002)
65 or older. (National Health and Nutrition Examination Survey
— The average annual rates of first major cardiovascular
[NHANES 1999–2002], CDC/NCHS. Bullet points below are also
events rise from 7 per 1,000 men at ages 35–44 to 68 per
from NHANES 1999–2002 unless otherwise noted.)
1,000 at ages 85–94. For women, comparable rates occur
The following are the latest estimates of prevalence for these 10 years later in life. The gap narrows with advancing age.
conditions. Due to overlap, it is not possible to add these — Under age 75, a higher proportion of CVD events due to
conditions to arrive at a total. coronary heart disease (CHD) occur in men than in women,
• High blood pressure (HBP) — 65,000,000. (Defined as and a higher proportion of events due to congestive heart
systolic pressure 140 mm Hg or greater and/or diastolic failure (CHF) occur in women than in men.
pressure 90 mm Hg or greater, taking antihypertensive • The aging of the population will undoubtedly result in an
medication or being told at least twice by a physician or increased incidence of chronic diseases, including coronary
other health professional that you have high blood pressure.) artery disease, heart failure and stroke. (Circulation
• Coronary heart disease — 13,000,000. 2002;106:1602–5)
— Myocardial infarction (heart attack) — 7,100,000. — The U.S. Census estimates that there will be 40 million
Americans age 65 and older in 2010.
— Angina pectoris (chest pain) — 6,400,000.
— There’s been an explosive increase in the prevalence of accidents, 2 percent for diabetes and 0.7 percent for HIV.
2 obesity and type 2 diabetes. Their related
complications — hypertension, hyperlipidemia and
atherosclerotic vascular disease — also have increased.
(U.S. Decennial Life Tables for 1989–91, Vol. 1, No. 4,
Sept. 1999)
• The CDC estimates that each year 400,000 to 460,000 people
— An alarming increase in unattended risk factors in the die of heart disease in an emergency department or before
younger generations will continue to fuel the reaching a hospital, which accounts for over 60 percent of all
cardiovascular epidemic for years to come. cardiac deaths. Heart disease death in this study included
• Among American Indian men ages 45–74, the incidence of deaths from all forms of heart disease (Diseases of the Heart)
CVD ranges from 1.5 to 2.8 percent. Among women it and congenital malformations of the heart (I00–I09, I11, I13,
ranges from 0.9 to 1.5 percent. (Strong Heart Study Data I20–I51, Q20–Q24). (Morbidity and Mortality Weekly Report
Book, NIH, NHLBI, Nov. 2001) [MMWR], Vol. 51, No. 6, Feb. 15, 2002, CDC/NCHS) See
the Out-of-Hospital Cardiac Deaths by State fact sheet,
• Among American Indians ages 65–74, the annual rates per
instructions on page 1a.
1,000 population of new and recurrent heart attacks are 6.8
for men and 2.2 for women (SHS[1991–98], NHLBI) • In 2001, the number of premature deaths (<65 years) from
diseases of the heart (I00–I09, I11, I13, I20–I51) was
greatest among American Indians or Alaska Natives (36
Mortality percent) and blacks (31.5 percent) and lowest among whites
CVD accounted for 38.0 percent of all deaths or 1 of every 2.6 (14.7 percent). Premature death was higher for Hispanics
deaths in the United States in 2002. CVD mortality was nearly 60 (23.5 percent) than non-Hispanics (16.5 percent), and for
percent of “total mortality.” This means that of over 2,400,000 males (24 percent) than females (10 percent). Hispanic
deaths from all causes, CVD was listed as a primary or whites (23.3 percent) had lower proportions than Hispanic
contributing cause on about 1,400,000 death certificates. blacks (27.5 percent), and non-Hispanic whites (14.4
• Since 1900 CVD has been the No. 1 killer in the United percent) had lower proportions than non-Hispanic blacks
States every year but 1918. Nearly 2,600 Americans die of (31.5 percent). (Behavioral Risk Factor Surveillance System,
CVD each day, an average of 1 death every 34 seconds. CDC/NCHS, MMWR, Vol. 53, No. 6, Feb. 20, 2004,
CVD claims about as many lives each year as the next 5 CDC/NCHS)
leading causes of death combined, which are cancer, chronic • Yearly totals of out-of-hospital death (ICD/9 codes: 390–398,
lower respiratory diseases, accidents, diabetes mellitus, and 402, and 404–429) in people ages 15 to 34 rose from 2,719
influenza and pneumonia. in 1989 to 3,000 in 1996. Alarmingly, though the numbers
• Other causes of death in 2002 — cancer 557,271; accidents are very small, the death rate increased by 30 percent in
106,742; Alzheimer’s disease 58,866; HIV (AIDS) 14,095. young women. Death rates were also higher among young
African Americans than among Caucasians. (Sudden
• The 2002 preliminary CVD death rates were 380.4 for Cardiac Death in U.S. Young Adults, 1989–96, CDC, 2001)
males and 273.4 for females. Cancer death rates were 238.9
for males and 163.1 for females. Breast cancer claimed the • Age-adjusted death rates for Diseases of the Heart from
lives of 41,514 females in 2002; lung cancer claimed 1990 to 1998 declined 15 percent for non-Hispanic whites,
67,542. The death rates were 25.6 for breast cancer and 41.6 11 percent for non-Hispanic blacks, 17 percent for
for lung cancer. 1 in 30 female deaths is from breast cancer, Hispanics, 14 percent for Asian or Pacific Islanders and 8
while 1 in 2.5 is from CVD. percent for American Indians or Alaska Natives. In 1998 the
rate for non-Hispanic blacks was 2.8 times the rate for Asian
• Over 150,000 Americans killed by CVD each year are under or Pacific Islanders. (Healthy People 2000, Statistical Notes,
age 65. In 2002, 32 percent of deaths from CVD occurred No. 23, CDC/NCHS, Jan. 2002)
prematurely (i.e., before age 75, the approximate average
life expectancy in that year).
Risk Factors
• The 2002 overall preliminary death rate from CVD was
320.5. The rates were 373.8 for white males and 492.5 for For statistics on individual CVD risk factors, see Chapter 9
black males; 265.6 for white females and 368.1 for black beginning on page 32.
females. From 1992 to 2002 death rates from CVD (ICD/10 • Among adults age 18 and older, the prevalence of 2 or more
I00–I99) declined 18.0 percent. In the same 10-year period risk factors increased from 23.6 percent in 1991 to 27.9
actual CVD deaths increased 0.8 percent. percent in 1999. It increased significantly for both men and
• Based on revised 2000 population data, the average life women and for all race, ethnic, age and education groups.
expectancy of people born in the United States is now 77.3 (BRFSS, CDC/NCHS, Arch Intern Med 2004;164:181–8)
years. According to the CDC/NCHS, if all forms of major — Among persons with 2 risk factors in 1999, the most
CVD were eliminated, life expectancy would rise by almost common combination was HBP and high cholesterol
7 years. If all forms of cancer were eliminated, the gain (23.9 percent).
would be 3 years. According to the same study, the
— Among those with 3 risk factors, the most common
probability at birth of eventually dying from major CVD
combination was HBP, high cholesterol and obesity
(I00–I78) is 47 percent, and the chance of dying from cancer
(32.5 percent).
is 22 percent. Additional probabilities are 3 percent for
— Among those with 4 risk factors, about 43 percent had among all disease categories in hospital discharges.
the combination of HBP, high cholesterol, obesity and
smoking. Another 40 percent had HBP, high
cholesterol, obesity and diabetes. These risk factor
(National Hospital Discharge Survey: 2001, CDC/NCHS)
• In 2002 there were 80,092,000 physician office visits with a
2
primary diagnosis of CVD. (National Ambulatory Medical
combinations were also the most common combinations Care Survey, 2002 Summary, CDC/NCHS)
in earlier years.
• In 2002 there were 4,648,000 visits to emergency
• Black and Mexican-American women have higher departments with a primary diagnosis of CVD. (National
prevalence of CVD risk factors than white women of Hospital Ambulatory Medical Care Survey, 2002 Emergency
comparable socioeconomic status (SES). (NHANES III Department Summary. CDC/NCHS)
[1988–94], CDC/NCHS, JAMA 1998;280:356–62)
• In 1999, 23 percent of nursing home residents age 65 or
• Among American Indians or Alaska Natives age 18 and older had a primary diagnosis of CVD at admission. This
older, 63.7 percent of men and 61.4 percent of women have was the highest disease category for these residents. (1999
one or more CVD risk factors (hypertension, current National Nursing Home Survey, USDHHS, June 2002)
cigarette smoking, high blood cholesterol, obesity or
• In 2002 there were 6,024,000 outpatient department visits
diabetes). If data on physical inactivity had been included in
with a primary diagnosis of CVD. (National Hospital
this analysis, the prevalence of risk factors probably would
Ambulatory Medical Care Survey, 2002 Outpatient
have been higher. (BRFSS [1997], CDC/NCHS)
Department Summary. CDC/NCHS)
• Data from the BRFSS survey on adults 18 and older, from
1991–2001, showed the prevalence of reported HBP, high
cholesterol, diabetes and obesity increased. The prevalence
Cost
of smoking remained nearly the same, and the prevalence of • In 2005 the estimated direct and indirect cost of CVD is
no known risk factors for diseases of the heart and stroke $393.5 billion. See page 53 for more detailed information.
declined. As a result, the national burden of Diseases of the
Heart and stroke is expected to increase. (MMWR, • In 1999, $26.3 billion in program payments were made to
Vol. 53(01);4–7, CDC/NCHS) Medicare beneficiaries discharged from short-stay hospitals,
with a principal diagnosis of cardiovascular disease. That
• Data from the BRFSS study of the CDC/NCHS showed that was an average of $7,883 per discharge. (Health Care
young women and men, ages 18 to 24, had poor health Financing Review, 2001 Medicare and Medicaid Statistical
profiles and experienced adverse changes from 1990 to Supplement, CMS, April 2003)
2000. After adjustment for education and income, these
young people had the highest prevalence of smoking (34–36 • A study of the 1987 National Medicaid Expenditure Survey
percent current smokers among whites); the largest increases and the 2000 Medical Expenditure Panel Survey, Household
in smoking (10–12 percent among whites and 9 percent Component, showed the 15 most costly medical conditions,
among Hispanic women); large increases in obesity (4–9 and the estimated percent increase in total healthcare
percent increase in all groups). All groups had high levels of spending for each condition from 1987–2000. The following
sedentary behavior (approximately 20–30 percent) and low are some of the top 15 conditions, by order of rank, and
vegetable or fruit intake (approximately 35–50 percent). In their percentage impact on health care spending:
contrast, older Hispanics and older black men, ages 65–74, heart disease (1) +8.06 percent; cancer (4) +5.36 percent;
showed some of the most positive changes. They had the hypertension (5) +4.24 percent; cerebrovascular disease (7)
largest decreases in smoking (Hispanic women), largest +3.52 percent; diabetes (9) +2.37 percent; and kidney
decreases in sedentary behavior (Hispanic women and black disease (15) +1.03 percent.
men), and largest increases in vegetable or fruit intake
(Hispanic women and black men). (Am J Health Promot Operations and Procedures
2004;19[1]:19–27)
• Data from the Chicago Heart Association Detection Project • In 2002 an estimated 6,813,000 inpatient cardiovascular
(1967–73) showed that in younger women (age 18–39) with operations and procedures were performed in the United
favorable levels for all five major risk factors (blood States; 4.0 million were performed on males and 2.8 million
pressure, serum cholesterol, BMI, diabetes and smoking), were performed on females. For more data, see pages 51
CHD and CVD are rare, and long-term and all-cause and 52. (CDC/NCHS)
mortality are much lower compared with others. (JAMA
2004;292:1588-92)
Hospital/Physician/Nursing
Home Visits
• From 1979 to 2002 the number of Americans discharged
from short-stay hospitals with CVD as the first listed
diagnosis increased 30 percent. In 2002 CVD ranked highest
2 Deaths From Diseases of the Heart
United States: 1900–2002
Percentage Breakdown of Deaths From Cardiovascular
Diseases
United States: 2002 Preliminary
800
Deaths in Thousands
700 0.4% Congenital

Cardiovascular 13% Other
600 53% Coronary
Defects Heart Disease
500
0.4% Rheumatic Fever/
400 Rheumatic Heart
300 Disease
4% Diseases
200 of the Arteries
100 5% High Blood
0 Pressure
1900 10 20 30 40 50 60 70 80 90 00 02
6% Congestive
Years Heart Failure
Note: See Glossary on page 58 for an explanation of “Diseases of 18% Stroke

the Heart.” Total cardiovascular disease data are not available
for much of the period covered by this chart.
Source: CDC/NCHS.
Source: CDC/NCHS .
Hospital Discharges for Cardiovascular Diseases Prevalence of Cardiovascular Diseases in Americans

United States: 1970–2002 Age 20 and Older by Age and Sex
NHANES: 1999–2002
86.4
7 90
77.8
80 75.0
6 Men 68.5
Discharges in Millions
Percent of Population
70
5 Women
60 52.9 56.5
4
50
3 40 36.2 36.6
22.9
2 30
17.6
1 20 11.2
10 6.2
0
1970 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02
0
20-34 35-44 45-54 55-64 65-74 75+
Years
Ages
Note: Hospital discharges include people both living and dead. Source: CDC/NCHS and NHLBI. These data include CHD, CHF, stroke and
hypertension.
Source: CDC/NCHS.
Leading Causes of Death for All Males and Females
United States: 2002
Leading Causes of Death for Black or African-American
Males and Females
United States: 2002
2
493,623
500
433,825 Males 45
39.6
Deaths in Thousands
Percent of Total Deaths

400 40
Females 33.4
Males
35
Females
300 288,768 268,503 30
25 22.2
20.9
200 20
69,257
15
100 60,713 64,103 41,877 10
34,301 38,948 5.9 5.2
4.7 3.7
5 2.8 2.7
0
A B C D E A B D F E 0
A B C D E A B F G C
A Total CVD (Preliminary) D Chronic Lower Respiratory Diseases A Total CVD (Preliminary) E HIV (AIDS)
B Cancer E Diabetes Mellitus B Cancer F Diabetes Mellitus
C Accidents F Alzheimer’s Disease C Accidents G Nephritis, Nephrotic Syndrome
D Assault (Homicide) and Nephrosis
Source: CDC/NCHS.
Note: Using “Diseases of the Heart, and Stroke,” which do not
constitute total CVD, the percentages of the “A” bars would
be 30.6 for males and 36.0 for females.
Source: CDC/NCHS.
Leading Causes of Death for White Males and Females Leading Causes of Death for Hispanic or Latino Males
United States: 2002 and Females
United States: 2002
45 45
39.8
40 40 Males
36.6 Males
35 35 32.2 Females
Females 30 27.1
30
24.4 25
25 21.6 21.2
18.6
20 20
15 15 11.7
10 10 6.1
5.7 5.4 5.6 4.2 4.0 4.7
5 2.7 3.6 3.1 5 2.8
0 0
A B C D E A B D F G A B C D E A B D C F
A Diseases of the Heart, D Diabetes Mellitus

A Total CVD (Preliminary) E Diabetes Mellitus
and Stroke E Assault (Homicide)
B Cancer F Alzheimer’s Disease
B Cancer F Chronic Lower Respiratory Disease
C Accidents G Influenza and Pneumonia
C Accidents
D Chronic Lower
Respiratory Diseases Source: CDC/NCHS.
Note: Using “Diseases of the Heart, and Stroke,” which do not
constitute total CVD, the percentages of the “A” bars would
be 34.1 for males and 36.8 for females.
Source: CDC/NCHS.
2 Leading Causes of Death for Asian or Pacific Islander
Males and Females
United States: 2002
Age-Adjusted Death Rates for Coronary Heart Disease,
Stroke, and Lung and Breast Cancer for White and
Black Females
United States: 2002
45 Males
40 200
35.8 Females
Per 100,000 Population

34.8 169.7
35
30 26.9 150 131.2 White Females
25.4
25 Black Females
20 100
15 71.8
53.4
10 42.6
5.7 4.0 50 40.1
5 3.6 3.2 3.9 3.0 25.0 34.0
0
A B C D E A B E C F 0
Coronary Stroke Lung Breast
Heart Cancer Cancer
A Diseases of the Heart, D Chronic Lower Disease
and Stroke Respiratory Diseases
B Cancer E Diabetes Mellitus Source: CDC/NCHS
C Accidents F Influenza and Pneumonia
Note: “Asian or Pacific Islander” is a heterogeneous category that

Cardiovascular Disease Mortality Trends for Males and
includes people at high CVD risk (South Asian) and people at
low CVD risk (Japanese). More specific data on these groups Females
aren’t available. United States: 1979-2002
520
Source: CDC/NCHS.
Deaths in Thousands
500
480
Leading Causes of Death for American Indian or Alaska 460
Native Males and Females 440
United States: 2002
420
400
45
Males 01979
40 81 83 85 87 89 91 93 95 97 99 01
35 Females Years
30
24.4 24.5 Males Females
25
19.3
20 16.0 Source: CDC/NCHS.
14.9
15
10 8.6 7.2
5.0 4.7 4.1
5
0
A B C D E A B C D F
A Diseases of the Heart, D Diabetes Mellitus

and Stroke E Chronic Liver Disease
B Cancer and Cirrhosis
C Accidents F Chronic Lower
Respiratory Diseases
Source: CDC/NCHS.
2001 Age-Adjusted Death Rates for Total Cardiovascular Disease, Coronary Heart Disease and Stroke by State
(includes District of Columbia and Puerto Rico)
Maps showing age-adjusted death rates by state for cardiovascular disease, coronary heart disease and stroke are available in the Death
Rates by State fact sheet at americanheart.org. See page 1a for instructions.
2
Total Cardiovascular Disease* Coronary Heart Disease** Stroke#
+ + +
Death Percent Change Death Percent Change Death Percent Change
State Rank## Rate 1991 to 2001 Rank## Rate 1991 to 2001 Rank## Rate 1991 to 2001
Alabama 49 379.4 –14.2 22 154.8 –22.2 44 66.0 –10.0

Alaska 9 276.8 –14.3 5 118.7 –30.2 23 57.4 +2.0
Arizona 6 272.6 –19.2 18 151.7 –24.2 6 48.2 –10.6
Arkansas 45 377.5 –11.9 39 186.0 –23.8 52 75.9 –11.5
California 27 313.9 –18.5 33 180.3 –24.4 34 61.2 –12.6
Colorado 5 267.9 –19.0 6 121.9 –35.4 16 53.9 –8.2
Connecticut 12 285.5 –21.5 13 146.5 –26.7 9 49.6 –12.0
Delaware 30 325.6 –22.5 43 192.9 –23.8 8 49.2 –18.2
District of Columbia 47 379.0 –8.7 50 218.1 +18.8 3 46.4 –30.6
Florida 21 300.8 –15.8 35 181.5 –21.2 5 47.6 –14.7
Georgia 43 364.0 –16.8 19 153.1 –31.0 46 67.4 –12.8
Hawaii 2 256.2 –18.0 1 101.7 –29.2 31 59.8 –7.9
Idaho 15 289.4 –17.8 11 136.8 –27.3 40 64.7 –11.1
Illinois 31 331.3 –21.7 31 178.9 –30.0 27 58.4 –13.3
Indiana 39 346.1 –17.7 29 174.4 –27.7 37 63.8 –11.6
Iowa 23 305.7 –19.6 30 177.3 –24.4 28 58.8 –7.9
Kansas 26 310.1 –15.8 14 148.7 –26.7 32 60.3 –6.2
Kentucky 48 379.0 –13.3 41 191.2 –21.9 39 64.4 –8.8
Louisiana 44 368.5 –19.8 36 182.3 –30.2 41 64.8 –13.2
Maine 20 296.8 –22.3 21 153.5 –29.9 17 54.7 –4.5
Maryland 32 332.0 –14.7 38 184.5 –19.1 30 59.6 +0.1
Massachusetts 10 280.2 –20.7 12 139.9 –32.2 7 48.6 –13.5
Michigan 42 357.0 –16.6 46 201.9 –26.2 26 58.2 –11.9
Minnesota 1 247.5 –27.2 3 113.2 –39.8 14 52.5 –23.1
Mississippi 52 424.2 –16.0 45 197.8 –25.2 48 70.5 –9.1
Missouri 41 355.9 –14.1 42 192.2 –20.7 35 61.6 –6.8
Montana 8 274.4 –19.5 4 116.2 –29.9 25 57.7 –14.4
Nebraska 18 292.7 –22.9 7 124.9 –37.2 22 57.3 –10.6
Nevada 34 336.3 –20.7 23 156.7 –31.8 18 55.1 –1.0
New Hampshire 24 307.2 –17.4 32 180.1 –21.6 12 52.0 –14.2
New Jersey 28 315.5 –19.7 40 187.2 –24.8 2 44.2 –20.0
New Mexico 7 273.4 –18.3 16 150.9 –21.4 10 49.6 –11.9
New York 36 340.0 –22.4 52 227.6 –27.5 1 38.4 –25.3
North Carolina 35 339.5 –20.1 28 170.6 –28.2 49 71.3 –12.5
North Dakota 19 296.0 –13.9 27 162.9 –18.3 33 60.4 –11.9
Ohio 40 352.5 –16.8 44 193.5 –23.8 24 57.4 –6.1
Oklahoma 51 391.6 –8.7 51 220.6 –9.2 43 65.6 –2.9
Oregon 13 285.8 –17.4 8 128.5 –34.9 47 69.5 –3.0
Pennsylvania 33 334.0 –19.6 34 180.4 –28.3 19 55.5 –10.6
Puerto Rico 4 265.8 — 9 130.1 — 13 52.2 —
Rhode Island 25 309.5 –17.8 47 202.5 –16.7 4 47.4 –18.4
South Carolina 38 344.1 –22.8 26 160.4 –30.4 51 75.0 –15.3
South Dakota 14 288.9 –22.4 24 158.2 –31.0 15 52.5 –5.4
Tennessee 46 377.7 –13.6 49 211.9 –19.2 50 72.3 –11.6
Texas 37 340.8 –13.1 37 183.8 –20.5 38 63.8 –8.0
Utah 3 262.7 –20.7 2 108.0 –35.4 21 56.4 –8.5
Vermont 17 292.6 –20.5 25 158.5 –31.6 11 50.2 –11.7
Virginia 29 317.5 –22.5 15 150.4 –28.7 42 65.4 –11.0
Washington 16 290.3 –18.5 17 151.2 –23.8 45 67.2 –7.1
West Virginia 50 382.6 –16.1 48 209.7 –21.6 29 59.4 –5.4
Wisconsin 22 304.4 –19.9 20 153.1 –29.9 36 61.7 –11.3
Wyoming 11 282.5 –16.9 10 136.2 –24.0 20 56.1 –15.1
Total United States 328.1 –18.8 177.8 –25.6 57.9 –11.4
Note: (—) = data not available.

* Total cardiovascular disease is defined here as ICD/10 I00–I99.
** Coronary heart disease is defined here as ICD/10 I20–I25.
#
Stroke is defined here as ICD/10 I60–I69.
##
Rank is lowest to highest.
+ Percent change is based on log linear slope of rates for each year, 1990–2001. For computing percent change, the death rates in 2001 were comparability modified using the
comparability ratio 1.0588 for stroke.
Source: NCHS compressed mortality file for the years 1979 to 2001.
Charts showing death rates for total cardiovascular disease, coronary heart disease, stroke and total deaths in selected countries are
included in the International Cardiovascular Disease Statistics fact sheet at americanheart.org. See page 1a for instructions.
Coronary Heart Disease,
3 Acute Coronary Syndrome
and Angina Pectoris
Coronary Heart Disease

(ICD/9 410–414, 429.2) (ICD/10 I20–I25; see Glossary for details and definitions)
New and Hospital

Prevalence Prevalence Recurrent Heart New and Mortality Mortality Discharges Cost
Population CHD MI Attacks and Recurrent CHD MI CHD CHD
Group 2002 2002 Fatal CHD MI 2002 2002 2002 2005
Total 13,000,000 7,100,000 1,200,000 865,000 494,382 179,514 2,125,000 $142.1

population (6.9%) (3.5%) billion
Total males 7,100,000 4,100,000 715,000 520,000 252,760 93,830 1,249,000 —
(8.4%) (5.0%) (51.1%)* (52.3%)*
Total females 5,900,000 3,000,000 485,000 345,000 241,622 85,684 875,000 —
(5.6%) (2.3%) (48.9%)* (47.7%)*
White males 8.9% 5.1% 650,000 — 223,262 83,288 — —
White females 5.4% 2.4% 425,000 — 211,908 74,634 — —
Black males 7.4% 4.5% 65,000 — 24,322 8,680 — —
Black females 7.5% 2.7% 60,000 — 25,852 9,642 — —
Mexican-American 5.6% 3.4% — — — — — —
males
Mexican-American 4.3% 1.6% — — — — — —
females
Hispanics or Latinos** 4.8% — — — — — — —
Asians** 5.0% — — — — — — —
American Indians or 3.6% — — — — — — —
Alaska Natives**
Note: CHD = coronary heart disease; includes acute myocardial infarction, other acute ischemic (coronary) heart disease, angina pectoris,
atherosclerotic cardiovascular disease, and all other forms of heart disease. MI = myocardial infarction (heart attack).
(—) = data not available.
* These percentages represent the portion of total mortality that is males vs. females.
** NHIS (2002) — data are for Americans age 18 and older.
Sources: Prevalence: NHANES (1999–02), CDC/NCHS and NHLBI; data for white and black males and females are for non-Hispanics. Total population data
are for Americans age 20 and older; percentages for racial/ethnic groups are age-adjusted for age 20 and older. These data are based on self
report. Incidence: ARIC (1987–2000), NHLBI. Mortality: CDC/NCHS; data for white and black males and females include Hispanics. Hospital
discharges: CDC/NCHS; data include people both living and dead. Cost: NHLBI; data include direct and indirect costs for 2005.
• Among Americans ages 40–74, NHANES data found the

Prevalence age-adjusted prevalence of self-reported MI and ECG-MI
• Coronary heart disease rates in women after menopause are (verified by electrocardiogram) to be higher among men
2–3 times those of women the same age before menopause. than women, but angina prevalence to be higher in women
(FHS, NHLBI, 44-year follow-up of participants and 20- than men. Age-adjusted rates of self-reported MI increased
year follow-up of their offspring) among African-American men and women and Mexican-
American men, but decreased among white men and women.
(Ethnicity & Disease, Vol. 13, p. 85–93, Winter 2003.)
Incidence
• This year an estimated 700,000 Americans will have a new
Mortality
Coronary heart disease caused 1 of every 5 deaths in the United
3
coronary attack. About 500,000 will have a recurrent attack. States in 2002. CHD total mention mortality — 656,000. MI total
(Atherosclerosis Risk in Communities [ARIC, 1987–2000, mention mortality — 225,000.
NHLBI] It is estimated that an additional 175,000 silent first
• CHD is the single largest killer of American males and
heart attacks occur each year.)
females. About every 26 seconds an American will suffer a
• The estimated incidence of myocardial infarction (MI) coronary event, and about every minute someone will die
(ICD/9 410) (ICD/10 I21, I22) is 565,000 new attacks and from one. About 41 percent of the people who experience a
300,000 recurrent attacks annually. (ARIC, 1987–2000, coronary attack in a given year, will die from it.
NHLBI)
• About 335,000 people a year die of CHD in an emergency
• The average age of a person having a first heart attack is department or before reaching a hospital. Most of these are
65.8 for men and 70.4 for women. (ARIC and CHS, NHLBI) sudden deaths caused by cardiac arrest, usually resulting from
• Based on the NHLBI’s FHS in its 44-year follow-up of ventricular fibrillation. (See also Arrhythmias, page 28.)
participants and the 20-year follow-up of their offspring: • A study of 1,275 HMO enrollees aged 50 to 79 years, who
(Hurst W. The Heart, Arteries and Veins. 10th ed. New York, had cardiac arrest (CA), showed the incidence of out-of-
NY: McGraw-Hill; 2002) hospital CA was 6.0/1,000 subject-years in subjects with any
— CHD comprises more than half of all cardiovascular clinically recognized heart disease compared to 0.8/1,000
events in men and women under age 75. subject-years in subjects without heart disease. In subgroups
— The lifetime risk of developing CHD after age 40 is 49 with heart disease, incidence was 13.6/1,000 subject-years in
percent for men and 32 percent for women. subjects with prior MI and 21.9/1,000 subject-years in
subjects with heart failure. (Am J Cardiol 2004;93:1455–60)
— The incidence of CHD in women lags behind men by 10
years for total CHD and by 20 years for more serious • An analysis of data from the FHS from 1950 to 1999
clinical events such as MI and sudden death. showed that overall CHD death rates decreased by 59
percent. Nonsudden CHD death decreased by 64 percent,
• In the NHLBI’s ARIC study, average age-adjusted CHD
and sudden cardiac death fell by 49 percent. These trends
incidence rates per 1,000 person-years were: white men,
were seen in men and women, in subjects with and without
12.5; black men, 10.6; white women, 4.0; and black women,
a prior history of CHD, and in smokers and nonsmokers.
5.1. Incidence rates excluding revascularization procedures
(Circulation 2004;110:522–7)
were: white men, 7.9; black men, 9.2; white women, 2.9;
and black women, 4.9. Hypertension was a particularly • From 1992 to 2002 the death rate from CHD declined 26.5
powerful risk factor for CHD in black persons, especially in percent, but the actual number of deaths declined only 9.9
black women. Diabetes was a weaker predictor of CHD in percent. In 2002 the overall CHD death rate was 170.8 per
black than in white persons. (Arch Intern Med 100,000 population. The death rates were 220.5 for white
2002;162:2565–71) males and 250.6 for black males, and 131.2 for white
females and 169.7 for black females. 1999 death rates for
• The annual rates per 1,000 population of new heart attack
CHD were 138.4 for Hispanics, 123.9 for American Indians
(MI or CHD death) in non-black men are 19.2 for ages
or Alaska Natives and 115.5 for Asian or Pacific Islanders.
65–74, 28.3 for ages 75–84, and 50.6 for age 85 and older.
(CDC/NCHS)
For non-black women in the same age groups the rates are
6.8, 14.2 and 33.2, respectively. For black men the rates are • Over 83 percent of people who die of CHD are age 65 or
21.6, 27.9 and 57.1, and for black women the rates are 8.6, older. (CDC/NCHS)
17.6 and 24.8, respectively. (CHS [1989–2000], NHLBI) • The estimated average number of years of life lost due to a
• Combining the rates for possible and definite CHD shows heart attack is 11.5. (NHLBI)
that 17 to 25 of every 100 American Indian men ages 45 to • Based on data from the FHS study of the NHLBI: (Hurst W.
74 had some evidence of heart disease. (Strong Heart Study The Heart, Arteries and Veins. 10th ed. New York, NY:
Data Book, NIH, NHLBI, Nov. 2001) McGraw-Hill; 2002)
• Among American Indians ages 65–74, the annual rates per — 25 percent of men and 38 percent of women will die
1,000 population of new and recurrent heart attacks are 6.8 within 1 year after having an initial recognized MI. In
for men and 2.2 for women. (SHS [1991–98], NHLBI) part because women have heart attacks at older ages
than men do, they’re more likely to die from them
within a few weeks. Almost half of men and women
under age 65 who have a heart attack (MI) die within
8 years.
— 50 percent of men and 64 percent of women who died
suddenly of CHD had no previous symptoms of
this disease.
— Between 70 and 89 percent of sudden cardiac deaths
3 occur in men, and the annual incidence is 3 to 4 times
higher in men than in women. However, this disparity
decreases with advancing age.
1988–94, and 1999–2000. (Manolio TA, et al. U.S. trends in
prevalence of low coronary risk. National Health and
Nutrition Examination Surveys. Circulation 2004;109:32.
— People who’ve had a heart attack have a sudden death Abstract P108.)
rate that’s 4–6 times that of the general population. — The prevalence of low risk rose from 6 percent in
— Sudden cardiac death accounts for 19 percent of sudden 1971–75 to 17 percent in 1988–94 and 1999–2000.
deaths in children between 1 and 13 years of age and 30 — Prevalence of low risk was about twice as high in
percent between 14 and 21 years. The overall incidence women as in men throughout the period.
is low, 600 cases per year. — Prevalence was initially higher in whites than in blacks
• According to data from the National Registry of Myocardial (7 percent vs. 3 percent in 1971–75); it increased more
Infarction (NRMI), (www.nrmi.org/nrmi_data.html) with time in blacks (17 percent vs. 15 percent in
— From 1990–1999, in-hospital AMI mortality declined 1999–2000).
from 11.2 percent to 9.4 percent. (J Am Coll Cardiol — Prevalence of low risk in 1999–2000 was lowest in those
2000;2056–63) ages 65–74 (3 percent) and was progressively greater at
— Mortality increases for every 30 minutes that elapse younger ages (29 percent at ages 25–34), with similar
before a patient with ST-segment elevation is recognized increases in prevalence over time across age groups.
and treated. (Am J Cardiol 2000;85:5B–9B) — The greatest changes in the components of low risk from
— Women under 50 are twice as likely to die after an AMI 1971 to 2000 were in prevalence of favorable diastolic
than men in the same age group. (NEJM blood pressure (38 to 71 percent), compared to favorable
1999;341:217–25) systolic blood pressure (32 to 47 percent), nonsmoking
(60 to 79 percent), and favorable cholesterol (33 to
46 percent).
Risk Factors • Taking into account CHD risk factors in combination
• A study of men and women in three prospective cohort provides a very potent predictor of 10-year risk of CHD
studies found that antecedent major CHD risk factor compared with individual risk factors. Among participants
exposures were very common among those who developed age 20–79 in the NHANES III study of the CDC/NCHS,
CHD. About 90 percent of the CHD patients have prior without self-reported CHD, stroke, peripheral vascular
exposure to at least one of these major risk factors, which disease and diabetes, 81.7 percent had a 10-year risk for
include high total blood cholesterol levels or current CHD of <10 percent, 15.5 percent had a risk of 10–20
medication with cholesterol-lowering drugs, hypertension or percent, and 2.9 percent had a risk of >20 percent. 40.3
current medication with blood pressure-lowering drugs, percent of men and 8.2 percent of women age 60 and over
current cigarette use, and clinical report of diabetes. (JAMA were at “intermediate risk (10–20 percent).” The proportion
2003;290:891–7) of participants with a 10-year risk of CHD of >20 percent
• According to a study of 52 countries (INTERHEART), nine increased with advancing age and was higher among men
easily measured and potentially modifiable risk factors than women but varied little with race or ethnicity. (J Am
account for over 90 percent of the risk of an initial acute MI. Coll Cardiol 2004;43:1791–6)
The effect of these risk factors is consistent in men and
women, across different geographic regions, and by ethnic Aftermath
group, making the study applicable worldwide. These nine
risk factors include cigarette smoking, abnormal blood lipid • Depending on their gender and clinical outcome, people
levels, hypertension, diabetes, abdominal obesity, a lack of who survive the acute stage of a heart attack have a chance
physical activity, low daily fruit and vegetable consumption, of illness and death that’s 1.5–15 times higher than that of
alcohol overconsumption, and psychosocial index. (Lancet the general population. The risk of another heart attack,
2004;364:937–52) sudden death, angina pectoris, heart failure and stroke — for
both men and women — is substantial. (FHS, NHLBI)
• A study of over 3,000 members of the FHS offspring cohort
(Hurst W. The Heart, Arteries and Veins. 10th ed. New York,
without CHD showed that among men with 10-year
NY: McGraw-Hill; 2002)
predicted risk for CHD of ≥ 20 percent, failure to reach
target heart rate and ST-segment depression both more than • A study conducted by the Mayo Clinic found that cardiac
doubled the risk of an event, and each MET (metabolic rehabilitation after a heart attack is underused, particularly in
equivalent) increment in exercise capacity reduced risk by women and the elderly. Women were 55 percent less likely
13 percent. (Circulation 2004;110:1920–5) than men to participate in cardiac rehabilitation, and older
study patients were less likely than younger participants.
• Low CHD risk is defined as blood pressure less than 120/80
Only 32 percent of men and women aged 70 or older
mm Hg, cholesterol less than 200 mg/dL and not currently
participated in cardiac rehabilitation, in comparison to 66
smoking. Age-adjusted prevalence was estimated in
percent of 60- to 69-year-olds and 81 percent of those under
nondiabetic persons without a history of MI participating in
age 60. (J Am Coll Cardiol 2004;44(5):988–96)
four NHANES surveys conducted in 1971–75, 1976–80,
• Within 6 years after a recognized heart attack (MI)… (FHS,
NHLBI) (Hurst W. The Heart, Arteries and Veins. 10th ed.
New York, NY: McGraw-Hill; 2002)
Acute Coronary
Syndrome 3
• 18 percent of men and 35 percent of women will have ( I C D / 9 c o d e s 4 1 0 , 4 11 )
another heart attack.
• 7 percent of men and 6 percent of women will experience The term ‘acute coronary syndrome’ (ACS) is increasingly used to
sudden death. describe patients who present with either acute myocardial
infarction or unstable angina (UA). (Unstable angina is chest pain
• About 22 percent of men and 46 percent of women will or discomfort that’s unexpected and usually occurs while at rest.
be disabled with heart failure. The discomfort may be more severe and prolonged than typical
• 8 percent of men and 11 percent of women will have angina or be the first time a person has angina.)
a stroke.
• 942,000 is a conservative estimate for the number of people
with ACS discharged from hospitals in 2002. Of these, an
Hospital Discharges estimated 543,000 are male and 399,000 are female. This
estimate is derived by adding the first listed hospital
• From 1979 to 2002 the number of Americans discharged
discharges for myocardial infarction (818,000) to those for
from short-stay hospitals with CHD as the first listed
unstable angina (124,000). (CDC/NCHS)
diagnosis increased 22 percent. (CDC/NCHS)
• When including secondary discharge diagnoses, the
• From 1990–1999, the median duration of hospital stay
corresponding number of hospital discharges was 1,673,000
related to acute myocardial infarction dropped from 8.3 days
unique hospitalizations for ACS, 973,000 for MI and
to 4.3 days, according to an analysis of the NRMI. Findings
728,000 for UA (28,000 hospitalizations received both
were similar for both patients receiving primary PTCA and
diagnoses). (CDC/NCHS)
those receiving thrombolytic therapy. (J Am Coll Cardiol
2000;2056–63) Decisions regarding medical and interventional treatments are
based on specific findings noted when a patient presents with
ACS. Such patients are classified clinically into one of three
Cost categories according to the presence or absence of ST segment
• In 2005 the estimated direct and indirect cost of CHD is elevation on the presenting electrocardiogram and abnormal
$142.1 billion. See page 53 for more detailed information. (“positive”) elevations of myocardial enzymes such as troponins,
as follows:
• In 1999, $10.7 billion was paid to Medicare beneficiaries for
CHD ($10,336 per discharge for acute MI; $11,270 per • ST elevation myocardial infarction (STEMI)
discharge for coronary atherosclerosis; and $3,472 per • non-ST elevation myocardial infarction
discharge for other CHD). (Health Care Financing Review,
• unstable angina
2001 Medicare and Medicaid Statistical Supplement, CMS,
April 2003) Studies evaluating the percentage of ACS patients who have
STEMI range from 30 to 45 percent. (NRMI-4 Steering
Committee; J Am Coll Cardiol 2003;41[suppl. A]:365A–366A)
Operations and Procedures
These are only preliminary estimates, in part because of
• In 2002 an estimated 1,204,000 angioplasty procedures, dramatically changing practices in the unstable angina discharge
515,000 bypass procedures, 1,463,000 diagnostic cardiac diagnosis in the past decade. Factors affecting the UA diagnosis
catheterizations, 63,000 implantable defibrillators and include changes in reimbursement policies, the advent of more
199,000 pacemaker procedures were performed in the sensitive assays for myocardial injury (leading to increased
United States. For more data, see pages 51 and 52. diagnosis of MI over unstable angina), and greater care of patients
(CDC/NCHS) in same-day “chest pain units” and same-day catheterization
procedures.
Estimated 10-Year CHD Risk in 55-Year-Old Adults Annual Rate of First Heart Attacks by Age, Sex and Race
3 According to Levels of Various Risk Factors
Framingham Heart Study
ARIC: 1987–2000
16 White Men
Black Men
White Women
Per 1,000 Persons

40
Estimated 10-Year Rate (%)
37
Men 12
35 Black Women
Women
30 25
27 8
25 20
20 4
13
15
10 8
5 5 0
5 35-44 45-54 55-64 65-74
0 Ages
A B C D
Source: NHLBI’s ARIC surveillance study, 1987–2000.
A B C D
Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90
Total Cholesterol (mg/dL) 200 240 240 240 Prevalence of Coronary Heart Disease by Age and Sex
HDL Cholesterol (mg/dL) 50 50 40 40 NHANES: 1999–2002
Diabetes No No Yes Yes
Cigarettes No No No Yes Men
mm Hg = millimeters of mercury Percent of Population 20 Women
mg/dL = milligrams per deciliter of blood 16.8
15
Source: Wilson PWF, et al. Prediction of coronary heart disease using risk 11.6 11.5
factor categories. Circulation. 1998;97:1837–1847. 10.3
10
6.3
5 3.0 3.6
Annual Number of Americans Having Diagnosed Heart 1.4 1.6
Attack by Age and Sex 0.0 0.3 0.2
ARIC: 1987–2000 0
20–34 35–44 45–54 55-64 65-74 75+
Ages
Men
500 Source: CDC/NCHS and NHLBI.
New and Recurrent Attacks
Women 410,000
400
in Thousands
372,000
300 250,000
200
88,000
100
34,000
10,000
0 29–44 45–64 65+
Ages
Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study,
1987–2000. These data don’t include silent MIs.
Hospital Discharges for Coronary Heart Disease by Sex Prevalence
• A study of four national cross-sectional health examination
studies found that, among Americans ages 40–74, the age-
3
1400
adjusted prevalence of angina pectoris (AP) was higher
Discharges in Thousands
1200 among women than men. Increases in the prevalence of AP

1000 occurred for Mexican-American men and women, and
800 African-American women, but were not statistically
significant for the latter. (Ethnicity & Disease
600 2003;13:85–93)
400
200 Incidence
01970 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 • Only 20 percent of coronary attacks are preceded by long-
Years standing angina. (44-year follow-up of participants and 20-
year follow-up of their offspring, FHS, NHLBI) (Hurst W.
Males Females The Heart, Arteries and Veins 10th ed. New York, NY:
McGraw-Hill; 2002)
Note: Hospital discharges include people both living and dead. • The annual rates per 1,000 population of new and recurrent
episodes of angina for non-black men are 44.3 for ages
Source: CDC/NCHS. 65–74, 56.4 for ages 75–84, and 42.6 for age 85 and older.
For non-black women in the same age groups the rates are
18.8, 30.8 and 19.8, respectively. For black men the rates are
26.1, 52.2 and 43.5, and for black women the rates are 29.4,
Angina Pectoris 37.7 and 15.2, respectively. (CHS, NHLBI)
(ICD/9 413) (ICD/10 I20)

Mortality
Population Prevalence Incidence of Hospital
A small number of deaths due to coronary heart disease are coded
Group 2002 Stable Angina Discharges — 2002*
as being from angina pectoris. These are included as a portion of
Total population 6,400,000 (3.8%) 400,000 58,000
total deaths from CHD.
Total males 3,100,000 (4.2%) — 23,000
Total females 3,300,000 (3.6%) — 35,000
White males 4.5% — —
White females 3.5% — —
Black males 3.1% — —
Black females 4.7% — —
Mexican-
American males 2.4% — —
Mexican-
American females 2.2% — —
Note: Angina pectoris is chest pain or discomfort due to insufficient

blood flow to the heart muscle. Stable angina is predictable
chest pain on exertion or under mental or emotional stress.
Sources: Prevalence: NHANES (1999–02), CDC/NCHS and NHLBI; data for
white and black males and females are for non-Hispanics;
percentages for racial/ethnic groups are age-adjusted for
Americans age 20 and older. Incidence: FHS, NHLBI. Hospital
discharges: CDC/NCHS; data include people both living and dead.
* There were 166,000 days of care for discharges from short-stay
hospitals in 2001.
4 Stroke
(ICD/9 430–438) (ICD/10 I60–I69)
Incidence Hospital 0.2 to 0.7 percent. (Strong Heart Study Data Book, NIH,
Population Prevalence New and Mortality Discharges Cost NHLBI, Nov. 2001)
Group 2002 Recurrent Attacks 2002 2002 2005 • The prevalence of silent cerebral infarction between ages 55
Total population 5,400,000 700,000 162,672 942,000 $56.8 billion to 64 is about 11 percent. This prevalence increases to 22
(2.6%) percent between ages 65 to 69, 28 percent between ages 70
Total males 2,400,000 327,000 62,622 432,000 — to 74, 32 percent between ages 75 to 79, 40 percent between
(2.5%) (47%)* (38.5%)* ages 80 to 85, and 43 percent above age 85. Applying these
Total females 3,000,000 373,000 100,050 509,000 — rates to 1998 U.S. population estimates results in an
(2.6%) (53%)* (61.5%)* estimated 13 million people with prevalent silent stroke.
White males 2.3% 277,000 52,959 — — (Stroke 1998;29:913–7; Radiology 2002;202:47–54)
White females 2.6% 312,000 86,760 — —
Black males 4.0% 50,000 7,828 — —
Incidence
Black females 3.9% 61,000 11,028 — —
Mexican- • On average, every 45 seconds someone in the United States
American males 2.6% — — — — has a stroke.
Mexican- • Each year about 700,000 people experience a new or
American females 1.8% — — — — recurrent stroke. About 500,000 of these are first attacks,
Hispanic or Latino** 2.4% — — — — and 200,000 are recurrent attacks. (GCNKSS, FHS, ARIC)
Asian** 2.4% — — — —
American Indian or • Each year about 40,000 more women than men have a
Alaska Native** 4.6% — — — — stroke. (CHS, NHLBI)
• Men’s stroke incidence rates are 1.25 times greater than
Note: (–) = data not available. women’s. The difference in incidence rates between the
* These percentages represent the portion of total incidence or sexes is somewhat larger at younger ages but nonexistent at
mortality that is males vs. females. older ages. The male/female incidence was 1.59 for ages
** NHIS (2002) — data are for Americans age 18 and older. 65–69; 1.46 for ages 70–74; 1.35 for ages 75–79 and 0.74
for age 80 and older. (CHS, NHLBI)
Sources: Prevalence: NHANES (1999–2002), CDC/NCHS and NHLBI; data
for white and black males and females are for non-Hispanics. • Of all strokes, 88 percent are ischemic, 9 percent are
Total population data include children; percentages for intracerebral hemorrhage, and 3 percent are subarachnoid
racial/ethnic groups are age-adjusted for Americans age 20 and hemorrhage. (GCNKSS, FHS, ARIC)
older. These data are based on self report. Incidence: FHS, • Blacks have almost twice the risk of first-ever stroke
GCNKSS, ARIC. Mortality: CDC/NCHS; data for white and black compared with whites. The age-adjusted stroke incidence
males and females include Hispanics. Hospital discharges:
rates (per 100,000) for first-ever strokes are 167 for white
CDC/NCHS; data include people both living and dead. Cost:
NHLBI; data include direct and indirect costs for 2005.
males, 138 for white females, 323 for black males and 260
for black females. (GCNKSS, FHS, ARIC)
• The Brain Attack Surveillance in Corpus Christi project
Prevalence (BASIC) clearly demonstrated an increased incidence of
• From the early 1970s to early 1990s, the estimated number stroke among Mexican Americans compared with non-
of noninstitutionalized stroke survivors increased from 1.5 Hispanic whites in this community. The crude cumulative
million to 2.4 million. (Stroke 2002;33:1209–13) incidence was 168/10,000 in Mexican Americans and
136/10,000 in non-Hispanic whites. Specifically, Mexican
• The prevalence of transient ischemic attacks (TIA) in men is
Americans have an increased incidence of intracerebral
2.7 percent for ages 65–69 and 3.6 percent for ages 75–79.
hemorrhage and subarachnoid hemorrhage than non-
(A TIA, or transient ischemic attack, is a mini-stroke that
Hispanic whites adjusted for age, as well as an increased
lasts less than 24 hours.) For women, TIA prevalence is 1.6
incidence of ischemic stroke and TIA at younger ages when
percent for ages 65–69 and 4.1 percent for ages 75–79. (Ann
compared with non-Hispanic whites. (Am J Epidemiol
Epidemiol 1993;3:504–7) (CHS, NHLBI)
2004;160:376–83)
• The prevalence of stroke in American Indian men ages
45–74 ranges from 0.2 to 1.4 percent and in women from
• The age-adjusted annual incidence rate (per 1,000) for total factor vs. 68 percent in 1995. Groups of people with the
stroke in Japanese-American men has declined markedly from
5.1 to 2.4; for thromboembolic stroke, from 3.5 to 1.9; and
for hemorrhagic stroke, from 1.1 to 0.6. The estimated average
highest risk and incidence of stroke — i.e., persons at least
75 years old, blacks and men — were the least
knowledgeable about warning signs and risk factors. (JAMA
4
annual declines are 5 percent for total stroke, 3.5 percent for 2003;289:343–6)
thromboembolic stroke, and 4.3 percent for hemorrhagic • TIAs carry a substantial short-term risk of stroke,
stroke. The decline in stroke mortality in the HHP target hospitalization for cardiovascular events and death. Of 1,707
population was similar to that reported for U.S. white males TIA patients evaluated in the emergency department (ED) of
ages 60–69 during the same period. (During the 1969–88 a large health care plan, 180 patients or 10 percent
follow-up period of the Honolulu Heart Program, NHLBI) developed stroke within 90 days. 91 patients or 5 percent did
• Among American Indians ages 65–74, the annual rates per so within 2 days. Predictors of stroke: more than 60 years of
1,000 population of new and recurrent strokes are 15.2 for age, having diabetes mellitus, focal symptoms of weakness
men and 7.9 for women. (SHS [1991–98], NHLBI) or speech impairment, and TIA lasting longer than 10
minutes. (JAMA 2000;284:2901–6)
Mortality • The relative risk of stroke in heavy smokers (more than 40
cigarettes a day) is twice that of light smokers (less than 10
Stroke accounted for more than 1 of every 15 deaths in the United cigarettes per day). Stroke risk decreases significantly after
States in 2002. About 50 percent of these deaths occurred out of two years and is at the level of nonsmokers by five years
hospital. Total mention mortality — about 275,000. after cessation of cigarette smoking. (JAMA
• When considered separately from other cardiovascular 1988;259:1025–9)
diseases, stroke ranks No. 3 among all causes of death, • Atrial fibrillation (AF) is an independent risk factor for
behind diseases of the heart and cancer. (CDC/NCHS) stroke, increasing risk about 5-fold. For details, see
• On average, every 3 minutes someone dies of a stroke. Arrhythmias on page 28. (Stroke 1991;22:983–8)
• 8–12 percent of ischemic strokes and 37–38 percent of • In adults over 55, the lifetime risk for stroke is greater than 1
hemorrhagic strokes result in death within 30 days. (Stroke in 6. Women have a higher risk than men, perhaps due to
1999;30:736–43; Stroke 1999;30:2517–22) their survival advantage. Blood pressure (BP) is a powerful
determinant of stroke risk. Subjects with BP less than
• From 1992 to 2002 the stroke death rate fell 13.8 percent,
120/80 mm Hg have about half the lifetime risk of stroke,
but the actual number of stroke deaths rose 6.9 percent.
compared to subjects with hypertension. (FHS, NHLBI,
(CDC/NCHS)
Seshadri, et al. Lifetime Risk of Stroke: Results from the
• The 2002 overall death rate for stroke was 56.2. Death rates Framingham Study)
were 54.2 for white males and 81.7 for black males; and
53.4 for white females and 71.8 for black females. 1999 Physical Activity
death rates for stroke were 40.0 for Hispanics, 52.4 for
Asian or Pacific Islanders, and 39.7 for American Indians or • Physical activity reduces stroke risk. Results from the
Alaska Natives. (CDC/NCHS) Physicians’ Health Study showed a lower stroke risk
associated with vigorous exercise among men (relative risk
• Because women live longer than men, more women than [RR] of total stroke = 0.86 for exercise 5 times a week or
men die of stroke each year. Women accounted for 61.5 more). (Stroke 1999;30:1–6) The Harvard Alumni Study
percent of U.S. stroke deaths in 2002. showed a decrease in total stroke risk in men who were
• From 1995 to 1998 age-standardized mortality rates for highly physically active (RR = 0.82). (Stroke
ischemic stroke, subarachnoid hemorrhage and intracerebral 1998;29:2049–54)
hemorrhage were higher among blacks than whites. Death • For women in the Nurses’ Health Study, RR for total stroke
rates from intracerebral hemorrhage were also higher among from the lowest to the highest physical activity levels were:
Asian or Pacific Islanders than among whites. All minority 1.00 (reference), 0.98, 0.82, 0.74 and 0.66, respectively.
populations had higher death rates from subarachnoid (JAMA 2000;283:2961–7)
hemorrhage than did whites. Among adults ages 25–44,
blacks and American Indians or Alaska Natives had higher • The Northern Manhattan Study — which included whites,
risk ratios than did whites for all three stroke subtypes. (Am blacks and Hispanics, and men and women in an urban
J Epidemiol 2001;154:1057–63) setting — showed a decrease in ischemic stroke risk
associated with physical activity levels across all
racial/ethnic and age groups, and for each gender (odds ratio
Risk Factors = 0.37). (Stroke 1998;29:380–7)
• In 2000, 70 percent of respondents correctly named at least
one established stroke warning sign vs. 57 percent in 1995.
72 percent correctly named at least one established risk
Pregnancy and Stroke • According to the NHLBI’s FHS… (Hurst W. The Heart,
4 • The Baltimore-Washington Cooperative Young Stroke Study
found the risk of ischemic stroke or intracerebral
Arteries and Veins. 10th ed. New York, NY: McGraw-
Hill; 2002)
hemorrhage during pregnancy and the first six weeks — 14 percent of persons who survive a first stroke or TIA
postpartum was 2.4 times greater than for nonpregnant will have another one within 1 year.
women of similar age and race. The risk of ischemic stroke — 22 percent of men and 25 percent of women who have
during pregnancy was not increased during pregnancy per an initial stroke die within a year. This percentage is
se, but was increased 8.7-fold during the six weeks higher among people age 65 and older.
postpartum. Intracerebral hemorrhage showed a small — 51 percent of men and 53 percent of women under age
relative risk (RR) of 2.5 during pregnancy, but increased 65 who have a stroke die within 8 years.
dramatically to an RR of 28.3 in the six weeks postpartum. — The length of time to recover from a stroke depends on
The excess risk of stroke (all types except subarachnoid its severity. 50 to 70 percent of stroke survivors regain
hemorrhage) attributable to the combined pregnant/post- functional independence, but 15 to 30 percent are
pregnant period was 8.1 per 100,000 pregnancies. (NEJM permanently disabled. 20 percent require institutional
1996;335:768–74) care at three months after onset.
• Using Swedish administrative data, it was found that • In the NHLBI’s FHS, among ischemic stroke survivors who
ischemic stroke and intracerebral hemorrhage, including were at least 65 years old, these disabilities were observed at
subarachnoid hemorrhage, are increased in association with 6 months post-stroke: (J Stroke Cerebrovasc Dis
pregnancy. The postpartum period and particularly the three 2003;12:119–26)
days surrounding delivery were times of increased risk.
However, overall risks for stroke in association with — 50 percent had some hemiparesis.
pregnancy was low. (Sources were used to compare the risk — 30 percent were unable to walk without some assistance.
of stroke among women in the third trimester of pregnancy, — 26 percent were dependent in activities of daily living.
around delivery [from 2 days before to 1 day after delivery], — 19 percent had aphasia.
and the puerperium [from 2 days to 6 complete weeks after
delivery] to the risk of stroke among nonpregnant and early — 35 percent had depressive symptoms.
pregnant [up to the first 27 gestational weeks] women. — 26 percent were institutionalized in a nursing home.
Subarachnoid hemorrhage, as well as ischemic stroke and
intracerebral hemorrhage, are increased in association with Hospital Discharges
pregnancy. The postpartum period and particularly the three
days surrounding delivery were times of increased risk.) • From 1979 to 2002 the number of Americans discharged
(Epidemiology 2001;12:456–60) from short-stay hospitals with stroke as the first listed
• Data from the HHP found that in elderly Japanese men ages diagnosis increased 26 percent. (CDC/NCHS)
71–93, low concentrations of HDL cholesterol were more • During 1988–97 the age-adjusted stroke hospitalization rate
likely to be associated with a future risk of thromboembolic increased 18.6 percent (from 560 to 664 per 100,000), while
stroke than were high concentrations. (Am J Epidemiol total hospitalizations increased 38.6 percent (from 592,811
2004;160:150–7) to 821,760). Hospitalization rates did not change for ages
35–64 but increased for persons age 65 and older. This
increase was greater for men than for women. The average
Aftermath length of hospital stay fell from 11.1 to 6.2 days. Total
• Stroke is a leading cause of serious, long-term disability in person-days in hospital decreased 22 percent. (Stroke
the United States. (MMWR, Vol. 50, No.7, Feb. 23, 2001, 2001;32:2221–6. Stroke in this study includes ICD/9
CDC/NCHS) 431–434 and 436–438. The American Heart Association
• The median time from stroke onset to arrival in an ER is uses 430–438.)
between 3 and 6 hours, according to a study of at least 48 • Between 1980 and 1999 the hospital discharge rates for
unique reports of prehospital delay time for patients with stroke increased for blacks and whites; the in-hospital
stroke, TIA or stroke-like symptoms. The study included mortality rates decreased for both black and white patients.
data from 17 countries, including the United States. Generally, the risk of a stroke hospitalization was more than
Improved clinical outcome at 3 months was seen for patients 70 percent greater for blacks than for whites. Both groups
with acute ischemic stroke when intravenous thrombolytic were similar in terms of in-hospital mortality rates.
treatment was started within 3 hours of the onset of (Neuroepidemiology 2002;21:131–41)
symptoms. (NEJM 1995;333:1581–7)
• In 1999 more than 1,100,000 American adults reported Cost
difficulty with functional limitations, activities of daily
living, etc., resulting from stroke. (MMWR, Vol. 50, No. 7, • In 2005 the estimated direct and indirect cost of stroke was
Feb. 23, 2001, CDC/NCHS) $56.8 billion. See page 53 for more detailed information.
• In 1999, $3.4 billion ($5,692 per discharge) was paid to • Stroke in childhood and young adulthood has a
Medicare beneficiaries discharged from short-stay hospitals
for stroke. (Health Care Financing Review, 2001 Medicare
and Medicaid Statistical Supplement, CMS, April 2003)
disproportionate impact on the affected patients, their family
and society, compared to stroke at older ages. Outcome of
childhood stroke was a moderate or severe deficit in 42
4
• The mean lifetime cost of ischemic stroke in the United percent of cases. (J Child Neurol 2000;15[5]:316–24)
States is estimated at $140,048. This includes inpatient care, • Compared to the stroke risk of white children, black children
rehabilitation and follow-up care necessary for lasting deficits. have a higher relative risk of 2.12, Hispanics a lower relative
(All numbers converted to 1999 dollars using the medical risk of 0.76, and Asians have a similar risk. Boys have a
component of CPI.) (Stroke 1996;27:1459–66) 1.28-fold higher risk of stroke than girls. There are no ethnic
• In a population study of stroke costs within 30 days of an differences in stroke severity or case-fatality, but boys have a
acute event, the average cost was $13,019 for mild ischemic higher case-fatality rate for ischemic stroke. The increased
strokes and $20,346 for severe ischemic strokes (4 or 5 on risk among blacks is not explained by the presence of sickle
the Ranking Disability Scale). (Neurology 1996;46:861–9) cell disease, nor is the excess risk among boys explained by
trauma. (Neurology 2003;61[2]:189–94)
• Inpatient hospital costs for an acute stroke event account for
70 percent of the first-year post-stroke costs. (Stroke • Despite current treatment, 1 out of 10 children with
1996;27:1459–66) ischemic stroke will have a recurrence within 5 years.
(Lancet 2002;360:1540–5)
• The largest components of acute care costs were room
charges (50 percent), medical management (21 percent) and • Cerebrovascular disorders are among the top 10 causes of
diagnostic costs (19 percent). (Stroke 1999;30:724–8) death in children, with rates highest in the first year of life.
Stroke mortality in children under 1 year of age has
• Mortality within seven days, subarachnoid hemorrhage, and
remained the same over the last 40 years. (Pediatrics
stroke while hospitalized for another condition are
2002;109[1]:116–23)
associated with higher costs in the first year. Conversely,
lower costs are associated with mild cerebral infarctions or • From 1979 to 1998 in the United States, childhood mortality
residence in a nursing home prior to the stroke. (Neurology from stroke declined by 58 percent overall, with reductions
1996;46:861–9) in all major subtypes. (Neurology 2002;59:34–9)
• Demographic variables (age, sex and insurance status) are — Ischemic stroke decreased by 19 percent, subarachnoid
not associated with stroke cost. Severe strokes (NIHSS score hemorrhage (SAH) by 79 percent, and intracerebral
greater than 20) cost twice as much as mild strokes, despite hemorrhage (ICH) by 54 percent.
similar diagnostic testing. Co-morbidities such as ischemic — Black ethnicity was a risk factor for mortality from all
heart disease and atrial fibrillation predict higher costs. (Stroke stroke types.
1999;30:724–8; Arch Intern Med 2003;163) — Male sex was a risk factor for mortality from SAH and
ICH but not from ischemic stroke.
Operations and Procedures • Sickle cell disease is the most important cause of ischemic
stroke among African-American children. The Stroke
• In 2002 an estimated 134,000 endarterectomy procedures
Prevention Trial in Sickle Cell Anemia (STOP)
were performed in the United States. Carotid
demonstrated the efficacy of blood transfusions for primary
endarterectomy is the most frequently performed surgical
stroke prevention in high-risk children with sickle cell
procedure to prevent stroke. For more data, see pages 51 and
disease in 1998. First admission rates for stroke in
52. (CDC/NCHS)
California among persons under age 20 with sickle cell
disease showed a dramatic decline subsequent to the
Stroke in Children publication of the STOP study. For the study years
1991–1998, 93 children with sickle cell disease were
• Stroke in children has a peak in the perinatal period. In the admitted to California hospitals with a first stroke; 92.5
National Hospital Discharge Survey from 1980–1998, the percent were ischemic and 7.5 percent were hemorrhagic.
rate of stroke for infants less than 30 days old (per 100,000 The first-stroke rate was 0.88 per 100 person-years during
live births per year) was 26.4, with rates of 6.7 for 1991–1998, compared to 0.50 in 1999 and 0.17 in 2000
hemorrhagic stroke and 17.8 for ischemic stroke (Pediatrics (p< 0.005 for trend). [Neurology 1998;51(1):169–76] [Blood
2002;109[1]:116–23) 2004;103(6):2391–6]
• The Greater Cincinnati/Northern Kentucky Stroke Study
found the stroke rate per 100,000 for children ages 1–14 was
2.7. The rate of ischemic stroke and intracerebral
hemorrhage is similar in this age group. (J Child Neurol
1993;8[3]:250–5; Neurology 1998;51[1]:169–76)
Risk of Stroke in Women in the Third Trimester, Peri- Annual Rate of First Cerebral Infarction by Age, Sex
4 and Post-Partum Period Versus Risk of Nonpregnant
Women and Women in the First 2 Trimesters
and Race
Greater Cincinnati/Northern Kentucky Stroke Study: 1993–94
30 White Males
100 95.0 Ischemic
24.7
Stroke 25 White Females 23.3
Per 1,000 Persons

21.8
80 Intracerebral Black Males
Relative Risk by
Stroke Subtype
Hemorrhage
20 16.8
Black Females 16.5
60 Subarachnoid 15 13.5
46.9 11.811.3
Hemorrhage 10.49.8
40 33.8 10
6.7
4.9 4.6 4.2
5 1.4 2.1 2.5 2.61.6
20 11.7 0.8
8.3 0.0 0.0 0.0 0.1 0.1 0.1 0.1 0.4
2.2 0.3 0.8 1.8 0
0 0-34 35-44 45-54 55-64 65-74 75-84 85+
Third Trimester Around Delivery Puerperium
Ages
Pregnancy Duration
Source: Unpublished data from the GCNKSS.
Source: Epidemiology 2001;12:456–60.
Annual Rate of First Intracerebral Hemorrhage by Age,
Sex and Race
Risk for Stroke Mortality Among Racial/Ethnic Groups Greater Cincinnati/Northern Kentucky Stroke Study: 1993–94
Compared With Non-Hispanic Whites, by Age
United States: 1997 2.5 2.3
White Males 2.2
4.0 3.9 2.1
4.0 2.0
3.5
35-44 65-74 Per 1,000 Persons White Females 1.8
3.0 45-54 75-84 Black Males 1.4 1.3
3.0 1.5
Relative Risk
1.3
55-64 85+ Black Females 1.2
2.5 1.0 1.0
1.9 1.9 1.0 0.9 0.9 0.9
2.0 0.6
1.5 0.6
1.5 1.3 1.3 1.2 1.3 1.3 1.4 1.3
1.2 1.1
1.0 0.9 0.5 0.3 0.3 0.3
0.9 0.9 0.2 0.1 0.2
1.0 0.6 0.7 0.8 0.10.1
0.5 0.0
0.5 0.4 0.0
35–44 45–54 55–64 65–74 75–84 85+
0.0
Non-Hispanic Hispanics Asian/Pacific American Indians/ Ages
Blacks Islanders Alaska Natives
Source: Stroke 2004;35:426–431.
Note: Values greater than 1.0 indicate populations with higher
relative risks. Values less than 1.0 indicate lower relative risks. Estimated 10-Year Stroke Risk in 55-Year-Old Adults
According to Levels of Various Risk Factors
Source: Age-specific excess deaths associated with stroke among Framingham Heart Study
racial/ethnic minority populations – United States, 1997, MMWR,
Vol. 49, No. 5, Feb.11, 2000, CDC/NCHS and NHLBI.
30 27.0
Estimated 10-Year Rate (%)
25 Men 22.4
Prevalence of Stroke by Age and Sex
NHANES: 1999–2002 Women 19.1
20
14.8
15
14
12.0 8.4
10
12 Men 11.5
5.4 6.3
5 4.0 3.5
10 Women 2.6 1.1 2.0
8 0
6.6 6.3 A B C D E F
6 A B C D E F
Systolic BP* 95–105 130–148 130–148 130–148 130–148 130–148
4 3.1 3.0
2.1 Diabetes No No Yes Yes Yes Yes
2 0.4 0.3
1.1 1.2 Cigarettes No No No Yes Yes Yes
0.8
Prior Atrial
0
20-34 35-44 45-54 55-64 65-74 75+ Fibrillation No No No No Yes Yes
Ages Prior CVD No No No No No Yes
* Blood pressures are in millimeters of mercury (mm Hg).
Source: CDC/NCHS and NHLBI.
Source: Stroke. 1991;22:312–318.
High Blood Pressure 5
(ICD/9 401–404) (ICD/10 I10–I15)
Hospital
• Overall, 39 percent of persons were normotensive, 31
Population Prevalence Mortality Discharges Cost percent were prehypertensive, and 29 percent were
Group 2002 2002 2002 2005 hypertensive. The age-adjusted prevalence of
Total population 65,000,000 49,707 535,000 $59.7 billion prehypertension was greater in men (39 percent) than in
(32.3%) women (23.1 percent). African Americans aged 20 to 39
Total males 29,400,000 20,512 224,000 — years had a higher prevalence of prehypertension (37.4
(31.5%) (41.3%)* percent) than whites (32.2 percent) and Mexican Americans
Total females 35,600,000 29,195 312,000 — (30.9 percent), but their prevalence was lower at older ages
(32.8%) (58.7%)* because of a higher prevalence of hypertension. (Arch Intern
White males 30.6% 14,713 — — Med 2004;164:2113–8)
White females 31.0% 22,329 — — • Of those with HBP, 30 percent don’t know they have it; 34
Black males 41.8% 5,268 — — percent are on medication and have it controlled; 25 percent
Black females 45.4% 6,311 — — are on medication but don’t have their HBP under control;
Mexican-American males 27.8% — — — and 11 percent aren’t on medication. (JNC 7; NHANES III)
Mexican-American females 28.7% — — — • A higher percentage of men than women have HBP until
Hispanic or Latino** 18.2% — — — age 55. After that a much higher percentage of women have
Asian** 16.7% — — — HBP than men do. (CDC/NCHS)
American Indians or 21.2% — — — • HBP is 2–3 times more common in women taking oral
Alaska Natives** contraceptives, especially in obese and older women, than in
women not taking them. (Fifth and Sixth Reports of the JNC
Note: (–) = data not available.
[JNC 5 and 6])
* These percentages represent the portion of total mortality that is
males vs. females. • About half of people who have a first heart attack and two-
thirds who have a first stroke have blood pressure higher than
Sources: Prevalence: NHANES (1999–2002), (Hypertension. 2004;44:398–404) 160/95 mm Hg. (FHS, NHLBI) (Hurst W. The Heart, Arteries
and NHLBI; data are age-adjusted for age 20 and older. Rates are
and Veins. 10th ed. New York, NY: McGraw-Hill; 2002)
for non-Hispanics.** NHIS (2002), CDC/NCHS; data are for
Americans age 18 and older. Mortality: CDC/NCHS; data for • People with systolic blood pressure of 160 mm Hg or higher
white and black males and females include Hispanics. Hospital and/or diastolic blood pressure of 95 mm Hg or higher have
discharges: CDC/NCHS; data include people both living and dead. a relative risk for stroke about 4 times greater than for those
Cost: NHLBI; data include direct and indirect costs for 2005. with normal blood pressure. (Hypertens Res 1994;17[suppl.
1]:S23–S32)
Prevalence • The prevalence of HBP among blacks and whites in the
southeastern United States is greater and death rates from
• High blood pressure (HBP) is defined as: stroke are higher than among those in other regions. (JNC 5
— systolic pressure of 140 mm Hg or higher, or diastolic and 6)
pressure of 90 mm Hg or higher • Hypertension precedes the development of congestive heart
— taking antihypertensive medicine failure (CHF) in 91 percent of cases. HBP is associated with
— being told at least twice by a physician or other health 2–3 times higher risk for developing CHF. (FHS, NHLBI,
professional that you have high blood pressure JAMA 1996;275:1557–62)
• “Prehypertension” is systolic pressure of 120–139 mm Hg,
or diastolic pressure of 80–89 mm Hg, and both not taking Race/Ethnicity and HBP
antihypertensive medication, or not being told on two
• The prevalence of hypertension in blacks in the United
occasions by a doctor or other health professional that you
States is among the highest in the world. Compared with
have hypertension.
whites, blacks develop HBP earlier in life and their average
• Nearly 1 in 3 adults has HBP. (Hypertension blood pressures are much higher. As a result, compared with
2004;44:398–404) whites, blacks have a 1.3 times greater rate of nonfatal
• About 28 percent of American adults age 18 and older or stroke, a 1.8 times greater rate of fatal stroke, a 1.5 times
about 59 million people, have “prehypertension.” (NHANES greater rate of heart disease death and a 4.2 times greater
1999–2002, CDC/NCHS, NHLBI) rate of end-stage kidney disease. (JNC 5 and 6)
• Within the African-American community, rates of Prevalence of High Blood Pressure in Americans by
5 hypertension vary substantially. (NHANES III [1988–94],

Prev Med 2002;35:303–12)
Age and Sex
NHANES: 1999–2002
— Those with the highest rates are more likely to be 90 83.4
middle-aged or older, less educated, overweight or 80 Men
74.0
obese, physically inactive, and to have diabetes. Women 69.2
70
— Those with the lowest rates are more likely to be 60.9
60 55.5
younger, but also overweight or obese.
50 46.6
— Those with uncontrolled HBP who are not on 40 34.134.0
antihypertensive medication tend to be male, younger
30
and have infrequent contact with a physician. 21.3
20 18.1
• Compared with white women, black women have an 85 11.1
5.8
10
percent higher rate of ambulatory medical care visits for
HBP. (Utilization of Ambulatory Medical Care by Women: 0
20–34 35–44 45–54 55–64 65–74 75+
United States, 1997–98, NCHS, 2001) Ages
• The awareness, treatment and control of HBP among those Source: CDC/NCHS and NHLBI.
in the Cardiovascular Health Study (CHS) age 65 and older
improved during the 1990s. The percentages who were
aware of and treated for HBP were higher among blacks
than among whites. Prevalences with HBP under control Age-Adjusted Prevalence Trends for High Blood
were similar. For both groups combined, the control of BP Pressure in Americans Ages 20–74 by Race/Ethnicity,
to lower than 140/90 mm Hg increased from 37 percent in Sex and Survey
1990 to 49 percent in 1999. Improved control was achieved NHANES: 1976–80, 1988–94 and 1999–2002
by an increase in antihypertensive medications per person
and by increasing the proportion of the CHS population 1976–80
60 1988–94
treated for hypertension from 34.5 percent to 51.1 percent. 50.7 51.1
(CHS, NHLBI, Arch Intern Med 2002;162:2325–32) 50 45.0 1999–02

39.4
• A study of children and adolescents from 1988–94 to 36.8 34.9
40 34.3
1999–2000, among ages 8 through 17 showed that among 33.7
23.4 23.4
non-Hispanic blacks, mean systolic blood pressure (BP) 30 23.9 23.3 25.6
22.6 18.4 22.5 22.5 20.9
levels increased 1.6 mm Hg among girls and 2.9 mm Hg 20
among boys, when compared with non-Hispanic whites.
Among Mexican Americans, girls’ systolic BP increased 1.0 10
mm Hg and boys’ increased 2.7 mm Hg higher when 0
compared with non-Hispanic whites. (JAMA Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic Mexican- Mexican-
White only White only Black or AA Black or AA American American
2004;291:2107–13) Men Women only Men only Women Men Women
Source: CDC/NCHS . Data based on a single measure of blood pressure.

Mortality
Total mention mortality — HBP was listed as a primary or
contributing cause of death in about 261,000 of over 2,400,000
U.S. deaths in 2002.
• From 1992 to 2002 the age-adjusted death rate from HBP
increased 26.8 percent, and the actual number of deaths rose
56.6 percent.
• The 2002 overall death rate from HBP was 17.1. Death
rates were 14.4 for white males, 49.6 for black males, 13.7
for white females and 40.5 for black females.
• As many as 30 percent of all deaths in hypertensive black
men and 20 percent of all deaths in hypertensive black
women may be due to HBP. (JNC 5 and 6)
Cost
• In 2005 the estimated direct and indirect cost of high blood
pressure is $59.7 billion. See page 53 for more detailed
information.
Extent of Awareness, Treatment and Control of High among different age, race, ethnicity and sex population groups.
Blood Pressure by Age
NHANES: 1999–2000
Morbidity rates tend to increase with age, then fall off for the
oldest age group. The age group with the highest incidence rate is
ages 75–79; for prevalence rates, it’s ages 70–74. Chronic kidney
5
80 73.3
69.8 disease (categorized in stages by level of estimated glomerular
70 66.4
62.9 62.7 filtration rate and urine proteins) which eventually progresses to
60 51.8 51.9 ESRD is also a substantial public health burden in the United
50 43.7 41.6 States. The excess CVD risk in people with chronic renal disease
40 is caused, in part, by a higher prevalence of CVD risk factors in
27.7 27.4
30 this group than in the general population. The main factors include
20 14.4 older age, high blood pressure, high blood cholesterol and lipids,
10 diabetes and physical inactivity. An independent, graded
association was observed between a reduced estimated glomerular
0
Awareness Treatment Control, Control, All filtration rate (GFR, an indicator of kidney function) and the risk
Treated Hypertensives of death, cardiovascular events, and hospitalization in a large,
community-based population of over 1 million men and women.
18-39 40-59 60+ (NEJM 2004;351:1296–305)
• The incidence of reported ESRD has almost doubled in the
Source: Trends in prevalence, awareness, treatment, and control of past 10 years. (NHLBI from usrds.org Web site)
hypertension in the United States, 1988–2000. JAMA.
• In 2002, 100,359 new cases of ESRD were reported.
2003;290:199–206.
• Over 424,000 patients were being treated for ESRD by the
end of 2002.
• 79,812 patients died from ESRD in 2002.
Extent of Awareness, Treatment and Control of High • More than 15,700 kidney transplants were performed in 2002.
Blood Pressure by Race/Ethnicity
NHANES: 1999–2000 • Diabetes continues to be the most common reported cause
of ESRD.
Non-Hispanic Whites • An estimated 11 percent or 19.2 million American adults
Non-Hispanic Blacks have between stage 1–4 chronic kidney disease. (Am J
Kidney Dis 2003;41(1):1–12)
80 73.9 Mexican Americans
69.5 • 3.2 percent of the Medicare population had a diagnosis of
70 63.0
chronic kidney disease between 1996 and 1997,
57.8 60.1
60 55.6
representing 63.6 percent of persons who progressed to
50 44.6
40.3
44.0 ESRD after one year. (Kidney International Supplement
40 33.4 2003;(87):S24–S31)
28.1
30
17.7
20 Age, Sex, Race and Ethnicity
10
0 • The average incidence rates for pediatric ESRD are more
Awareness Treatment Control, Control, All than twice as high among children ages 15–19 as for
Treated Hypertensives children ages 10–14. The rates are more than 3 times higher
Source: Trends in prevalence, awareness, treatment, and control of than those for children ages 0–4 and 5–9.
hypertension in the United States, 1988–2000. JAMA. • Children with pediatric ESRD have high transplantation rates.
2003;290:199–206. More than 44 percent of children starting therapy received a
transplant during the first year of therapy, compared with 10
percent of patients ages 20–64 at ESRD incidence.
End-Stage Renal
• The median age of the prevalent population is 58.1 years
Disease (ESRD) (59.2 for whites, 56.1 for blacks, 56.7 for Hispanics, 58.9
(ICD/10 N18.0) for Asians and 57.5 for Native Americans). (USRDS 2004
Annual Data Report. NIH, NIDDK)
ESRD (also called end-stage kidney disease) is a condition closely
• Treatment of ESRD is more common in men than in women.
related to high blood pressure, and occurs when the kidneys can
no longer function normally on their own. When this happens, • Blacks and Native Americans have much higher rates of
patients are required to undergo treatment such as kidney dialysis ESRD than whites and Asians. Blacks represent 29 percent
or a kidney transplant. ESRD morbidity rates vary dramatically of treated ESRD patients.
Congenital
6 Cardiovascular Defects
(ICD/9 745–747) (ICD/10 Q20–Q28)
Hospital treatment for all types of defects have improved substantially over
Population Mortality Discharges the past decade, and since some patients may have been unaware
Group 2001 2002 of their diagnosis at the time of the survey. (CDC/NCHS, HIS
Total population 4,109 51,000 Survey, 1993–95. Unpublished data.)
Total males 2,199 (53.5%)* 25,000
Total females 1,910 (46.5%)* 25,000 Incidence
White males 1,759 —
White females 1,493 — Major defects are usually apparent in the neonatal period, but
Black males 363 — minor defects may not be detected until adulthood. Thus, true
Black females 339 —
measures of incidence for congenital heart disease would need to
record new cases of defects presenting anytime in fetal life
through adulthood. However, estimates are only available for new
cases detected between birth and 30 days of life, known as birth
* These percentages represent the portion of total mortality that is prevalence, or as new cases detected in the first year of life only.
males vs. females. Both of these are typically reported as cases per 1,000 live births
Sources: Mortality: CDC/NCHS; data for white and black males and per year, and do not distinguish between tiny defects that resolve
females include Hispanics. Hospital discharges: CDC/NCHS; data without treatment and major malformations. To distinguish more
include people both living and dead. serious defects, some studies also report new cases of sufficient
severity to undergo an invasive procedure or result in death within
the first year of life. Despite the absence of true incidence figures,
Congenital cardiovascular defects, also known as congenital heart some data are available, and are shown in the Table on the
defects, are structural problems arising from abnormal formation next page.
of the heart or major blood vessels. At least 15 distinct types of
• According to the CDC, 1 in every 110 babies in the
congenital defects are recognized, with many additional anatomic
metropolitan Atlanta area was born with a congenital heart
variations.
defect, including some infants with tiny defects that
Defects range in severity from tiny pinholes between chambers resolved without treatment. Some defects occur more
that are nearly irrelevant and often resolve spontaneously, to major commonly in males or females, or in whites or blacks.
malformations that result in fetal loss or death in infancy or (MACDP, Pediatrics 2001;107)
childhood. Common complex defects include: • 9.0 defects per 1,000 live births are expected, or 36,000
• tetralogy of Fallot (9–14 percent) babies per year in the United States. Of these, several
studies suggest that 9,200, or 2.3 per 1,000 live births,
• transposition of the great arteries (10–11 percent)
require invasive treatment or result in death in the first year
• atrioventricular septal defects (4–10 percent) of life. (BWIS; Moller, 1998)
• coarctation of the aorta (8–11 percent) • Estimates are also available for bicommisural aortic valves,
• hypoplastic left heart syndrome (4–8 percent) occurring in 13.7 per 1,000 people; these defects may not
• ventricular septal defects (VSDs), the most common defect. require treatment in infancy, but can cause problems later in
Many close spontaneously, but VSDs still account for 14–16% adulthood. (J Am Coll Cardiol 2002;39:1890–900; Am J
of defects requiring an invasive procedure within the first Cardiol 1984;53:849–55)
year of life. (Perspectives in Pediatric Cardiology, Vol. 6, • Some studies suggest that as many as 5 percent of
Futura Publishing Company, Armonk, N.Y., 1998) newborns, or 200,000 per year, are born with tiny muscular
ventricular septal defects, almost all of which close
Prevalence spontaneously. (J Am Coll Cardiol 1995;26:1545–8; Arch
Dis Child Fetal Neonatal Ed 1999;81:F61–F63) These
About 1 million Americans, or 3.4 per 1,000, reported being told defects nearly never require treatment, so they aren’t
by a physician that they had a congenital cardiovascular defect, included in the Table on the next page.
according to a national interview survey in 1993–95. The current
prevalence is likely to be higher, since both diagnosis and
Annual Incidence of Congenital • In 2000 over 25,000 cardiovascular operations for congenital
Cardiovascular Defects
Type of Presentation Rate per 1,000 Live Births Number

heart disease were performed on children less than 20 years
of age. Inpatient mortality after all types of cardiac surgery
was 4.7 percent. However, mortality risk varies substantially
6
Fetal loss Unknown Unknown for different defect types, from 0.3 percent for atrial septal
Invasive procedure defect repair to 20.1 percent for first stage palliation for
during first year 2.3 9,200 hypoplastic left heart syndrome. 54 percent of operations
Detected during first year* 9.0 36,000 were performed in males. In unadjusted analyses, mortality
Bicommisural aortic valve 13.7 54,800 after cardiac surgery was somewhat higher for females than
Other defects detected for males (4.8 percent versus 4.6 percent). (Healthcare Cost
after first year Unknown Unknown and Utilization Project, HCUP KID2000)
Total Unknown Unknown • Mortality from congenital defects has been declining. From
* Includes stillbirths and pregnancy termination at less than 20 1979–97 age-adjusted death rates from all defects declined
weeks gestation; includes some defects that resolve 39 percent, and deaths tended to occur at progressively older
spontaneously or don’t require treatment. ages. However, 43 percent of deaths still occurred in infants
less than 1 year old. Mortality varies considerably according
Mortality to type of defect. (Circulation 2001;103:2376–81)
• From 1991 to 2001 death rates for congenital cardiovascular
• Total mention mortality — 6,100. defects declined 27.1 percent, while the actual number of
• Congenital cardiovascular disease is the most common deaths declined 26.1 percent.
cause of infant death from birth defects; 1 in 3 infants who
die from a birth defect have a heart defect. (NVSS Final
Data for 2000)
Hospitalizations
• The 2001 overall death rate for congenital cardiovascular In 2000 over 130,000 hospitalizations, as a primary or secondary
defects was 1.5. Death rates were 1.6 for white males, 2.0 diagnosis, occurred in infants or children with congenital
for black males, 1.4 for white females and 1.6 for black cardiovascular disease; hospital charges were $6.5 billion.
females. Crude infant death rates (under 1 year) were 44.0 (HCUP KID2000)
for white babies and 56.2 for black babies.
• In 2000, 213,000 life years were lost before age 65 due
to deaths from congenital cardiovascular disease. This is
nearly equivalent to the life years lost from leukemia,
prostate cancer and Alzheimer’s disease combined.
(CDC/NCHS; NHLBI)
7 Congestive Heart Failure
(ICD/9 428.0) (ICD/10 I50.0)
Hospital Incidence
Population Prevalence Incidence Mortality Discharges Cost
Group 2002 (New Cases) 2001 2002 2005 • Based on the 44-year follow-up of the NHLBI’s FHS…
Total population 4,900,000 550,000 52,828 970,000 $27.9 billion (Hurst W. The Heart, Arteries and Veins. 10th ed. New York,
(2.3%) NY: McGraw-Hill; 2001)
Total males 2,400,000 — 19,805 441,000 — — CHF incidence approaches 10 per 1,000 population
(2.6%) (37.5%)*
after age 65.
Total females 2,500,000 — 33,023 529,000 —
(2.1%) (62.5%)*
— 75 percent of CHF cases have antecedent hypertension.
White males 2.5% — 17,782 — — — About 22 percent of male and 46 percent of female
White females 1.9% — 29,942 — — heart attack (MI) victims will be disabled with heart
Black males 3.1% — 1,802 — —
failure within 6 years.
Black females 3.5% — 2,797 — — • Based on 1971 to 1996 data from the NHLBI’s FHS…
(Circulation 2002;106:3068–72)
Mexican-
American males 2.7% — — — — — At age 40, the lifetime risk of developing CHF for both
Mexican- men and women is 1 in 5.
American females 1.6% — — — —
— At age 40, the lifetime risk of CHF occurring without
Note: (–) = data not available. antecedent MI is 1 in 9 for men and 1 in 6 for women.
— The lifetime risk doubles for people with blood pressure
* These percentages represent the portion of total mortality that is
males vs. females.
greater than 160/90 mm Hg vs. those with pressure less
than 140/90 mm Hg.
Sources: Prevalence: NHANES (1999–2002), CDC/NCHS and NHLBI; data
• The annual rates per 1,000 population of new and recurrent
for white and black males and females are for non-Hispanics;
percentages are age-adjusted for Americans age 20 and older.
CHF events for non-black men are 21.5 for ages 65–74,
These data are based on self reports. Incidence: FHS, NHLBI. 43.3 for ages 75–84, and 73.1 for age 85 and older. For non-
Mortality: CDC/NCHS; data for white and black males and black women in the same age groups the rates are 11.2, 26.3
females include Hispanics. Hospital discharges: CDC/NCHS; data and 64.9, respectively. For black men the rates are 21.1,
include people both living and dead. Cost: NHLBI; data include 52.0 and 66.7, and for black women the rates are 18.9, 33.5
direct and indirect costs for 2005. and 48.4, respectively. (CHS, NHLBI)
• A community-based cohort study conducted in Olmsted
County, Minn., showed that the incidence of heart failure
Prevalence (ICD9/428) has not declined during two decades, but
survival after onset had increased overall, with less
• In a study conducted in Minnesota, 20.8 percent of the
improvement among women and elderly persons. (JAMA
population had mild diastolic dysfunction, 6.6 percent had
2004;292:344–50)
moderate diastolic dysfunction and 0.7 percent had severe
diastolic dysfunction. 5.6 percent had moderate or severe
diastolic dysfunction with normal ejection fraction (EF). Risk Factors
The prevalence of any systolic dysfunction was 6.0 percent
• A study of the predictors of heart failure among women
and moderate or severe systolic dysfunction was 2.0
with CHD found that diabetes was the strongest risk factor.
percent. Congestive heart failure (CHF) was much more
Diabetic women with elevated BMI or depressed creatinine
common among those with systolic or diastolic dysfunction
clearance were at highest risk with annual incidence rates of
than in those with normal ventricular function. Even among
7 and 13 percent respectively. Among nondiabetic women
those with moderate or severe diastolic or systolic
with no risk factors, the annual incidence rate was 0.4
dysfunction, less than half had recognized CHF. Mild
percent. The rate increases with each additional risk factor,
diastolic dysfunction and moderate or severe diastolic
and nondiabetic women with 3 or more risk factors had an
dysfunction were predictive of all-cause mortality. (JAMA
annual incidence of 3.4 percent. Among diabetic
2003;289:194–202)
participants with no additional risk factors, the annual
incidence of heart failure was 3.0 percent compared with 8.2
percent among diabetics with at least 3 additional risk Prevalence of Congestive Heart Failure by Sex and Age
factors. Diabetics with fasting glucose >300 mg/dL had a
threefold adjusted risk of developing heart failure, compared
with diabetics with controlled fasting blood sugar levels.
NHANES: 1999–2002
9.8 10.9
7
10
(Circulation 2004;110:1424–30)
Men
8
Women
Mortality 5.8
6.2
6
Total mention mortality — 264,900. 4.1
4
• Based on the 44-year follow-up of the NHLBI’s FHS… 2.3
— 80 percent of men and 70 percent of women under age 2 1.8

1.5
65 who have CHF will die within 8 years. 0.3 0.3 0.5 0.4
0
— After CHF is diagnosed, survival is poorer in men than 20-34 35-44 45-54 55-64 65-74 75+
in women, but fewer than 15 percent of women survive Ages
more than 8–12 years. The 1-year mortality rate is high, Source: CDC/NCHS and NHLBI.
with 1 in 5 dying.
— In people diagnosed with CHF, sudden cardiac death
occurs at 6–9 times the rate of the general population.
Hospital Discharges for Congestive Heart Failure by Sex
• From 1992 to 2002, deaths from heart failure (ICD 428) United States: 1970–2002
increased 35.3 percent. In the same time period, the death
rate increased 7.7 percent. 600
Discharges in Thousands
• The 2001 overall death rate for CHF was 18.7. Death rates
were 19.6 for white males, 21.7 for black males, 18.1 for 500
white females and 18.8 for black females. 400
300
Hospital Discharges
200
• Hospital discharges for CHF rose from 377,000 in 1979 to
970,000 in 2002, an increase of 157 percent. 100
0
1970 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02
Cost Years
• In 2005 the estimated direct and indirect cost of CHF in the Males Females
United States is $27.9 billion. See page 53 for details.
• In 1999, $3.6 billion ($5,456 per discharge) was paid to Note: Hospital discharges include people both living and dead.
Medicare beneficiaries for CHF. (Health Care Financing
Review, 2001 Medicare and Medicaid Statistical
Supplement, CMS, April 2003) Source: CDC/NCHS.
Other Cardiovascular
8 Diseases
Mortality, prevalence and death rate data in this section are for women (22.8). (MMWR, Vol. 52, No. 7, Feb. 21, 2003,
2001 or 2002. Total mention mortality is for 2001. Hospital CDC/NCHS)
discharge data are based on ICD/9 codes. • The most common diseases listed as the primary diagnosis
for persons hospitalized with AF were congestive heart
failure (11.8 percent), followed by AF (10.9 percent), CHD
Arrhythmias (Disorders of (9.9 percent), and stroke (4.9 percent). (MMWR, Vol. 52,
Heart Rhythm) No. 7, Feb. 21, 2003, CDC/NCHS)
(ICD/9 426, 427) (ICD/10 I46–I49) • AF is an independent risk factor for stroke, increasing risk
about 5-fold. The risk for stroke attributable to AF increases
with age. (Stroke 1991;22:983–8)
Mortality — 37,892. Total mention mortality — 480,400 of over
2,400,000 U.S. deaths. Hospital discharges — 858,000. In 1999, • AF is responsible for about 15–20 percent of all strokes.
$2.2 billion ($6,041 per discharge) was paid to Medicare (JAMA 2001;285:2370–5)
beneficiaries for cardiac dysrhythmias. (Health Care Financing • AF is also an independent risk factor for stroke recurrence
Review, 2001 Medicare and Medicaid Statistical Supplement, and stroke severity. A recent report showed people who had
CMS, April 2003) AF and were not treated with anticoagulants had a 2.1-fold
increase in risk for recurrent stroke and a 2.4-fold increase
Atrial fibrillation and flutter (ICD/9 427.3) (ICD/10 I48).
in risk for recurrent severe stroke. (Am J Med
Mortality — 9,451. Total mention mortality — 73,300.
2003;114:206–10)
Prevalence — about 2,200,000. (MMWR, Vol. 52, No. 7, Feb. 21,
2003, CDC/NCHS) Hospital discharges — 465,000. • People who have strokes caused by AF have been reported
as 2.23 times more likely to be bedridden compared to those
• In the FHS study, the lifetime risk for development of AF is who have strokes from other causes. (Neuroepidemiology
1 in 4 for men and women 40 years of age and older. 2003;22:118–23)
Lifetime risks for AF are high (1 in 6), even in the absence
• Participants in the FHS Offspring Study of the NHLBI were
of antecedent CHF or MI. (Circulation 2004;110:1042–6)
examined between 1984 to 1987 and monitored for 10
• Data from the National Hospital Discharge Survey (from years. Data show that symptoms of anger and hostility were
1996 to 2001) on cases that included AF as a primary predictive of 10-year incidence of AF in men. (Am J
discharge diagnosis found that: (Am J Cardiol Epidemiol 2004;159:950–8)
2004;94:500–4)
• Participants in the FHS study of the NHLBI were followed
— About 44.8 percent of patients were men. from 1968–1999. At age 40, lifetime risks for AF were 26.0
— The mean age for men was 66.8 years vs. 74.6 percent for men and 23.0 percent for women. At 80 years,
for women. lifetime risks for AF were 22.7 percent for men and 21.6
— The racial breakdown for admissions was 71.2 percent percent for women. In further analysis, counting only those
white, 5.6 percent black, and 2.0 percent other races. who had development of AF without prior or concurrent
20.8 percent were not specified. congestive heart failure or MI, lifetime risk for AF was
approximately 16 percent. (Circulation 2004;110:1042–6)
— African-American patients were much younger than
patients of other races. • Tachycardia (ICD/9 427.0,1,2) (ICD/10 I47.0,1,2,9).
Mortality — 6,496. Total mention mortality — 7,500.
— The incidence in men ranged from 20.58/100,000
Hospital discharges — 87,000.
persons per year for patients ages 15 to 44 to
1,077.39/100,000 persons per year for patients ages 85 • Paroxysmal supraventricular tachycardia (ICD/9
and older. In women the incidence ranged from 427.0) (ICD/10 I47.1). Mortality — 137. Hospital
6.64/100,000 persons per year for patients ages 15 to 44 discharges — 30,000.
years to 1,203.7/100,000 persons per year for those ages Ventricular fibrillation (ICD/9 427.4) (ICD/10 I49.0).
85 and older. Mortality — 1,406. Total mention mortality — 14,500. Hospital
— From 1996 to 2001, hospitalizations with AF as the first- discharges — 8,000. Ventricular fibrillation is listed as the cause
listed diagnosis, increased 34 percent. of relatively few deaths, but the overwhelming number of sudden
cardiac deaths from coronary disease (estimated at about 335,000
• Age-adjusted death rates for AF were highest among whites
per year) is thought to be from ventricular fibrillation.
(25.7) and blacks (16.4) and higher for men (34.7) than
• PAD affects 12–20 percent of Americans age 65 and older
Arteries, Diseases of
(ICD/9 440–448) (ICD/10 I70–I79) (Includes
peripheral arterial disease)
(4.5–7.6 million). By 2050 the prevalence could reach
9.6–16 million among those age 65 and older and 19 million
overall. Despite its prevalence and cardiovascular risk
8
implications, only 25 percent of PAD patients are
undergoing treatment. (J Vasc Interv Radiol 2002;13:7–11)
Mortality — 38,748 Total mention mortality — 118,300. Hospital
discharges — 272,000. • Based on current epidemiologic projections, 27 million
people in Europe and North America have PAD. An
Aortic aneurysm (ICD/9 441) (ICD/10 I71). Mortality — 15,234. estimated 10.5 million are symptomatic and 16.5 million are
Total mention mortality — 21,100. Hospital discharges — 61,000. asymptomatic. The prevalence of asymptomatic PAD was
Atherosclerosis (ICD/9 440) (ICD/10 I70) is a process that leads estimated in one study to be as high as 20 percent of the
to a group of diseases characterized by a thickening of artery adult population. (Arch Intern Med 2003;163)
walls. Mortality — 14,086. Total mention mortality — 68,900. • In the general population, only about 10 percent of persons
Hospital discharges — 111,000. Atherosclerosis causes many with PAD have the classic symptoms of intermittent
deaths from heart attack and stroke and accounts for nearly three- claudication (IC). About 40 percent do not complain of leg
fourths of all deaths from CVD. (FHS, NHLBI) pain, while the remaining 50 percent have a variety of leg
symptoms different from classic claudication. (JAMA
• In 1999 U.S. community hospitals billed $26.2 billion for 2001;286:11, 1317–24; Circulation 1985;71:516–22)
coronary atherosclerosis, more than for any other condition.
(AHRQ Electronic Newsletter, June 14, 2002) • The risk factors for PAD are similar to those for CHD,
although diabetes and cigarette smoking are particularly
Other diseases of arteries (ICD/9 442–448) (ICD/10 I72–I78). strong risk factors for PAD. (Am J Epidemiol
Mortality — 10,084. Hospital discharges — 100,000. 1989;129:1110–9)
• Kawasaki disease (ICD/9 446.1) (ICD/10 M30.3). Total • Persons with PAD have impaired function and quality of
mention mortality — 6. Up to 2,500 cases of Kawasaki life. This is true even for persons who do not report leg
disease are diagnosed yearly. Hospital discharges — 6,000, symptoms. Furthermore, PAD patients, including those who
primary plus secondary diagnoses. [Pediatr Infect Dis J are asymptomatic, experience significant decline in lower
1994;13(8)] extremity functioning over time. (Ann Intern Med
— About 80 percent of Kawasaki disease patients are under 2002;136:873–83; JAMA 2004;292:453–61)
age 5; most are under age 2. Children older than 8 years • PAD is a marker for systemic atherosclerotic disease.
are rarely affected. (NEJM 1998;339:93–104) Persons with PAD, compared to those without, have 4–5
— Kawasaki disease occurs more often among boys (63 times the risk of dying of a CVD event, resulting in 2–3
percent) and among those of Asian ancestry. (Pediatr times higher total mortality risk. (NEJM 1992;326:381–6;
Infect Dis J 1994;13:8) JAMA 1993;270:487–9)
— The highest incidence in the United States is in Hawaii. • In the Framingham Heart Study (FHS), the incidence of
A hospitalization rate of 47.7 per 100,000 children under PAD was based on symptoms of IC in subjects ages 29–62.
age 5 was reported during the mid-1990s. In the Annual incidence of IC per 10,000 subjects at risk rose from
continental United States, the estimated incidence is 6 in men and 3 in women ages 30–44 to 61 in men and 54
from 9 to 19 per 100,000 children. (Pediatrics in women ages 65–74. (Clin Cornerstone 2002;4:1–15)
2003;112:495–501) • Several studies have evaluated both symptomatic and
Peripheral arterial disease (PAD) affects 8 to 12 million asymptomatic PAD using the ABI. The prevalence of
Americans and is associated with significant morbidity and asymptomatic PAD was 25.5 percent among 1,537
mortality. (JAMA 2001;286:1317–24; NEJM 1992;326:381–6) participants of the Systolic Hypertension in the Elderly
Program (SHEP). (Clin Cornerstone 2002;4:1–15)
• A study from the NHANES 1999–2000 data found that PAD
affects about 5 million adults. Prevalence increases • In the FHS the annual mortality rate was almost 4 times
dramatically with age and disproportionately affects blacks greater in subjects with IC. In a major cohort study,
(Circulation 2004;110:738–43). However, the measurement investigators observed a 3.1 times higher risk for all-cause
of systolic blood pressure utilizing the right arm only and mortality compared with patients without PAD. In addition,
the omission of queries for surgical procedures to correct PAD patients had a 5.9 times higher risk for death from
PAD in this study led to an underestimate of the true PAD CVD complications and a 6.6 times higher risk for death
prevalence. Experts in the field generally agree that PAD from CHD specifically. (Clin Cornerstone 2002;4:1–15;
affects approximately 8 to 12 million Americans (JAMA NEJM 1992;326:381–6)
200;286:1317–24; NEJM 1992;326:381–6). • In the Genetic Epidemiology Network of Arteriopathy
(GENOA) study of the NHLBI, a comparison between
African Americans and non-Hispanic whites found that after
adjusting for age, African Americans had a greater preva-
8 lence of PAD (women 34 percent vs. 22 percent; men 33
percent vs. 11 percent). (Vasc Med 2003 Nov;8(4):237–42)
Rheumatic Fever/Rheumatic
Heart Disease
• Data from NHANES, 1999–2000 (CDC/NCHS), show that (ICD/9 390–398) (ICD/10 I00–I09)
even low blood levels of lead and cadmium may increase the
risk of PAD. Exposure to these two metals is possible
through cigarette smoke. The risk was 2.8 for high levels of Hospital
cadmium and 2.9 for high levels of lead. The odds ratio of Population Mortality Discharges
PAD for current smokers was 4.13 compared to people who Group 2002 2002
had never smoked. (Circulation 2004;109:3196–201) Total population 3,579 52,000
Total males 1,078 (30.1%)* 19,000
Bacterial Endocarditis Total females 2,501 (69.9%)* 33,000

White males 950 —
(ICD/9 421.0) (ICD/10 I33.0) White females 2,254 —
Black males 93 —
Total mention mortality — 2,421. Hospital discharges — 17,000, Black females 159 —
primary plus secondary diagnoses.

Cardiomyopathy * These percentages represent the portion of total mortality that is
(ICD/9 425) (ICD/10 I42) males vs. females.
Sources: Mortality: CDC/NCHS; data for white and black males and
females include Hispanics. Hospital discharges: CDC/NCHS; data
Mortality — 26,863. Total mention mortality — 54,600. Hospital
include people both living and dead.
discharges — 36,000.
• 87 percent of cases are congestive or dilated
cardiomyopathy. 50 percent of patients with dilated
Incidence
cardiomyopathy are alive 5 years after their initial diagnosis; • Many operations on heart valves are related to rheumatic
25 percent are alive 10 years after the diagnosis. (Facts heart disease (RHD).
About Cardiomyopathy, NIH, NHLBI, 1995) • The incidence of rheumatic fever (RF) remains higher in
• Mortality from cardiomyopathy is highest in older persons, African Americans, Puerto Ricans, Mexican Americans and
men and blacks. (FHS, NHLBI) American Indians. (Hurst W. The Heart, Arteries and Veins.
• Tachycardia-induced cardiomyopathy develops slowly and 10th ed. New York, NY: McGraw-Hill; 2001)
appears reversible, but recurrent tachycardia causes rapid
decline in left ventricular function and development of heart Mortality
failure. Sudden death is possible. (Circulation
2004;110:247–52) • Total mention mortality —6,975
• Since 1996 the NHLBI’s Pediatric Cardiomyopathy Registry • In 1950 about 15,000 Americans (adjusted for changes in
has collected data on all children with newly diagnosed ICD codes) died of RF/RHD compared with about
cardiomyopathy in New England and the Central Southwest 3,500 today.
(Texas, Oklahoma and Arkansas). (NEJM • From 1992 to 2002 the death rate from RF/RHD fell 23.5
2003;348:1647–55) percent, while actual deaths declined 39.1 percent.
— The overall incidence of cardiomyopathy is 1.13 cases • The 2002 overall death rate for RF/RHD was 1.2. Death
per 100,000 in children younger than age 18. rates were 0.9 for white males and 0.8 for black males, 1.5
— In children under 1 year the incidence is 8.34 and in for white females and 1.0 for black females.
children from 1 year to age 18 it’s 0.70 per 100,000.
— The annual incidence is lower in white than black
children; higher in boys than girls; higher in New
England (1.44 per 100,000) than in the Central
Southwest (0.98 per 100,000).
• Studies show that 36 percent of young athletes who die
suddenly have probable or definite hypertrophic
cardiomyopathy. (JAMA 1996;276:199–204)
• Data from the ARIC study of the NHLBI showed the 28-day
Valvular Heart Disease
(ICD/9 424) (ICD/10 I34–I38)
fatality from DVT is 9 percent; from PE, 15 percent; from
idiopathic DVT or PE, 5 percent; from secondary non-
cancer-related DVT or PE, 7 percent; and secondary cancer-
8
related DVT or PE, 25 percent. (Am J Med
Mortality — 19,737. Total mention mortality — 42,060. Hospital
2004;117(1):19–25)
discharges — 98,000.
• Deep vein thrombosis (ICD/9 451.1) (ICD/10 I80.2).
• Aortic valve disorders (ICD/9 424.1) (ICD/10 I35). Mortality — 2,730. Total mention mortality — 10,200.
Mortality — 12,380. Total mention mortality — about Hospital discharges — 8,000.
26,200. Hospital discharges — 56,000.
• A review of nine studies conducted in the United States and
• Mitral valve disorders (ICD/9 424.0) (ICD/10 I34). Sweden showed that the mean incidence of first DVT in the
Mortality — 2,865. Total mention mortality — about 7,000. general population was 5.04 per 10,000 person-years. The
Hospital discharges — 39,000. incidence was similar in males and females and increased
— The NHLBI’s FHS reports that among people ages dramatically with age from about 2–3 per 10,000 person-
26–84, prevalence is about 1–2 percent and equal years at ages 30–49 to 20 at ages 70–79. (Eur J Vasc
between women and men. Endovasc Surg 2003;25:1–5)
• Pulmonary valve disorders (ICD/9 424.3) (ICD/10 I37). • Death occurs in about 6 percent of DVT cases within one
Mortality — 12. Total mention mortality — 34. month of diagnosis. (Circulation 2003;107:I-4–I-8)
• Tricuspid valve disorders (ICD/9 424.2) (ICD/10 I36). • Pulmonary embolism (ICD/9 415.1) (ICD/10 I26).
Mortality — 3. Total mention mortality — 46. Mortality — 8,627. Total mention mortality — 26,400.
Hospital discharges — 99,000.
Operations and Procedures • In the Nurses Health Study, nurses age 60 or older in the
highest BMI quintile had the highest rates of pulmonary
• In 2002 an estimated 93,000 valve procedures were embolism. (BMI is body mass index; see Glossary on page
performed in the United States. For more data, see pages 51 58 for definition.) Heavy cigarette smoking and high blood
and 52. (CDC/NCHS) pressure were also identified as risk factors for PE. (NEJM
1998;339:93–104)
Venous Thromboembolism • Death occurs in about 12 percent of PE cases within one
month of diagnosis. (Circulation 2003;107:I-4–I-8)
• Venous thromboembolism (VTE) occurs for the first time in
• A study of Medicare recipients age 65 and older reported 30-
about 100 persons per 100,000 each year in the United
day case fatality rates in patients with PE. Overall, men had
States. About one-third of patients with symptomatic VTE
higher fatality rates than women (13.7 percent vs. 12.8
manifest pulmonary embolism (PE), whereas two-thirds
percent), and blacks had higher fatality rates than whites (16.1
manifest deep vein thrombosis (DVT) alone. (Circulation
percent vs. 12.9 percent). (NEJM 1998;339:93–104)
2003;107:I-4–I-8)
• In the International Cooperative Pulmonary Embolism
• Caucasians and African Americans have a significantly
Registry, the three-month mortality rate was 17.5 percent. In
higher incidence than Hispanics and Asian or Pacific
contrast, the overall three-month mortality rate in the
Islanders. (Circulation 2003;107:I-4–I-8)
Prospective Investigation of Pulmonary Embolism Diagnosis
• In studies conducted in Worcester, Mass., and Olmsted was 15 percent, but only 10 percent of deaths during one
County, Minn., the incidence of VTE was about 1 in 1,000. year of follow-up were ascribed to PE. (NEJM
In both studies VTE was more common in men; for each 10- 1998;339:93–104)
year increase in age, the incidence doubled. By
• The age-adjusted rate of deaths from pulmonary
extrapolation, it’s estimated that more than 250,000 patients
thromboembolism (PTE) decreased from 191 per million in
are hospitalized annually with VTE. (NEJM
1979 to 94 per million in 1998 overall, decreasing 56
1998;339:93–104)
percent for men and 46 percent for women. During this time
• The crude incidence rate per 1,000 person-years was 0.80 in the age-adjusted mortality rates for blacks were consistently
the ARIC study, 2.15 in CHS and 1.08 in the combined 50 percent higher than those for whites, and those for whites
cohort. Half of the participants who developed incident VTE were 50 percent higher than those for people of other races
were women and 72 percent were white. (Am J Med (Asian, American Indian, etc.). Within racial strata, mortality
2002;113:636–42) rates were consistently 20 to 30 percent higher among men
• Over 200,000 new cases of VTE occur annually. Of these, than among women. (Arch Intern Med 2003;163:1711–7)
30 percent die within three days; one-fifth suffer sudden
death due to PE. About 30 percent develop recurrent VTE
within 10 years. Independent predictors for recurrence
include increasing age, obesity, malignant neoplasm and
extremity paresis. (Seminars in Thrombosis and Hemostasis.
Vol. 28, Suppl. 2, 2002)
9 Risk Factors
Tobacco
Cigarette Smoking, Overall Prevalence

Prevalence Youth
Population Group Prevalence • In 2003 for grades 9–12, 30.3 percent of male students and
2002 24.6 percent of female students reported current tobacco
Total population 48,500,000 (22.5%) use; 19.9 percent of males and 9.4 percent of females
Total males 26,300,000 (25.2%) reported current cigar use; and 11.0 percent of males and
Total females 21,200,000 (20.0%) 2.2 percent of females reported current smokeless tobacco
White males 25.2% use. (Youth Risk Behavior Surveillance [YRBS], United
White females 20.7% States, 2003, MMWR, Vol. 53, No. SS-2, May 21, 2004,
Black or African-American males 27.0% CDC/NCHS)
Black or African-American females 18.5%
• About 80 percent of people who use tobacco begin before
Hispanic or Latino males # 23.2% age 18. The most common age of initiation is 14 to 15.
Hispanic or Latino females # 12.5%
(MMWR, Vol. 48, No. 31, Aug. 1999, CDC/NCHS)
Asian only males # 21.3%
Asian only females # 6.9% • White youths ages 18–24 from families with lower
American Indian or Alaska Native only males # 32.0% educational attainment report substantially higher smoking
American Indian or Alaska Native only females # 36.9% rates than black and Mexican-American youths from
families with similar educational attainment. 77 percent of
Note: Data are crude percentages for age 18 and older. young white men and 61 percent of young white women are
# — Data are for 1999–2001. smokers compared with 35 percent of minority youth.
Source: Health, United States, 2003 & 2004, CDC/NCHS. (JAMA 1999;281:1006–13)
• From 1980 to 2002 the percentage of high school seniors
who smoked in the past month decreased 12.5 percent. This
Cigarette Smoking, Prevalence percentage decreased by 2.2 percent in males, 23.7 percent
by Race/Ethnicity, Age and Sex in females, 0.3 percent in whites and 55.2 percent in blacks
or African Americans. (Health, United States, 2003,
Population Ages 12–17 Age 18 and older CDC/NCHS)
Group Males Females Males Females • An estimated 150,000–300,000 children younger than 18
Non-Hispanic: months of age have respiratory tract infections because of
White 14.9% 17.2% 29.1% 25.9%
exposure to secondhand smoke. (CDC/NCHS)
Black 8.2% 5.9% 30.1% 22.2%
Hispanic: 11.4% 10.2% 29.2% 17.3% • Children’s exposure to secondhand smoke, as indicated by
Mexican 11.4% 10.6% 29.8% 15.6% cotinine levels, dropped between 1988–94 and 1999–2000.
Puerto Rican 11.2% 10.4% 34.2% 27.3% Overall, 64 percent of children ages 4–11 had cotinine in
Central or South American 9.9% 9.3% 26.3% 16.9% their blood in 1999–2000, down from 88 percent in
Cuban 14.3% 10.0% 21.1% 17.5% 1988–94. In 1999–2000, 86 percent of non-Hispanic black
Asian: 8.8% 7.3% 24.1% 9.1% children ages 4–11 had cotinine in their blood compared to
Chinese 6.3% 5.4% 19.3% 5.9% 63 percent of non-Hispanic white children and 49 percent of
Filipino 5.8% 8.9% — 6.9%
Mexican-American children. The percentage of homes with
Japanese — — 18.3% —
children under age 7 in which someone smokes on a regular
Asian Indian 10.1% 6.8% 20.0% 3.0%
Korean 13.8% 7.3% — —
basis decreased from 29 percent in 1994 to 19 percent in
Vietnamese — 8.0% — — 1999. (America’s Children: Key National Indicators of Well-
American Indian or Alaska Native 29.5% 26.3% 40.9% 40.0% Being, 2003. Federal Interagency Forum on Child and
Hawaiian or Other Pacific Islander 7.0% NR NR NR Family Statistics, Washington, D.C.: U.S. Government
TOTAL 13.3% 14.2% 29.2% 24.1% Printing Office)
Note:(—) = data not available; NR = data considered unreliable.

Source: Percentage of persons ages 12–17 and age 18 and older reporting
cigarette use during the preceding month, by race/ethnicity and
sex: National Survey on Drug Use and Health, U.S., 1999–2001,
MMWR, Vol. 53, No. 3, Jan. 30, 2004, CDC/NCHS.
• Among children under age 18, an estimated 22 percent are — Cigarette smokers are 2–4 times more likely to develop
exposed to secondhand smoke in their homes, with estimates
ranging from 11.7 percent in Utah to 34.2 percent in
Kentucky. (MMWR, Vol. 46, No. 44, 1997, CDC/NCHS)
CHD than nonsmokers.
— Cigarette smoking approximately doubles a person’s risk
9
for stroke.
Adults — Cigarette smokers are more than 10 times as likely as
nonsmokers to develop peripheral vascular disease
• Since 1965 smoking in the United States has declined by 47 (PVD).
percent among people age 18 and older. (Health, United
States, 2004, CDC/NCHS)
Mortality
• Among Americans age 18 and older, 25.2 percent of men
and 20.0 percent of women are smokers, putting them at • From 1995 to 1999 an average of 442,398 Americans died
increased risk of heart attack and stroke. (Health, United each year of smoking-related illnesses. 33.5 percent of these
States, 2004, CDC/NCHS) deaths were cardiovascular-related. (MMWR, Vol. 51, No.
• Use of any tobacco product in 2001 was 31.3 percent for 14, 2002, CDC/NCHS)
white only, 27.7 for black or African-American only, 44.9 • About 35,000 nonsmokers die from CHD each year as a
for American Indian or Alaska Native only, 28.5 for Native result of exposure to environmental tobacco smoke.
Hawaiian or other Pacific Islander only, 13.6 for Asian only (MMWR, Vol. 51, No. 14, 2002, CDC/NCHS)
and 22.9 for Hispanic or Latino, any race. (Health, United • On average, male smokers die 13.2 years earlier than male
States, 2003, CDC/NCHS) nonsmokers, and female smokers die 14.5 years earlier
• Smoking prevalence is higher among those with 9–11 years than female nonsmokers(Surgeon General’s Health
of education (35.4 percent) compared with those with more Consequences of Smoking 2004)
than 16 years of education (11.6 percent). It’s highest among • Current cigarette smoking is a powerful independent
persons living below the poverty level (33.3 percent) predictor of sudden cardiac death in patients with CHD.
compared with other income groups. (MMWR, Vol. 48, No. (Arch Intern Med 2003;163:2301–5)
43, 1999, CDC/NCHS) • Cigarette smoking results in a 2-to-3 fold risk of dying from
• About 60 percent of people in the U.S. have biological CHD. (Tobacco-Related Mortality, Fact Sheet.
evidence of secondhand smoke exposure. (Second National CDC.gov/tobacco. Feb. 2004)
Report on Human Exposure to Environmental Chemicals:
Tobacco Smoke. CDC/NCHS 2003:80)
Health Consequences
• Data from the BRFSS study of the CDC/NCHS show that
more than one-third of white men and women ages 18–24 • Data from The Health Consequences of Smoking, 2004 — A
smoked, the highest rate among all the groups covered in the Report of the Surgeon General (CDC/NCHS): A study of
survey in 2000. Those young people and Hispanic women women younger than 44 years of age found there was a
the same age had the largest increases in smoking rates from strong dose-relationship for MI, with a risk of 2.5 for those
1990–2000. More than half of men and women ages 18–24 smoking 1 to 5 cigarettes per day, rising to 74.6 for those
from all ethnic groups failed to quit smoking in 2000. smoking more than 40 cigarettes per day, compared with
Younger white women and men ages 18–44 had higher nonsmokers.
overall risk levels for noncommunicable diseases, probably • Another study on female smokers found the highest risk
due to increased smoking and obesity. (Am J Health Promot (6.8) for MI was in women younger than 55 years of age.
2004;19(1):19)
• One-third of those who receive percutaneous coronary artery
• According to the World Health Organization (WHO), 1 year vascularization are current smokers, and 50 to 60 percent
after quitting, the risk of CHD decreases by 50 percent. continue to smoke after the procedure.
Within 15 years, the relative risk of dying from CHD for an
• Cigarette smoking remains a major cause of stroke in the U.S.
ex-smoker approaches that of a long-time (lifetime)
The evidence is sufficient to infer a causal relationship
nonsmoker. (World No-Tobacco Day 1998,
between smoking and subclinical atherosclerosis.
www.who.ch/ntday/ntday98)
• From 61.3 percent to 82.1 percent of adults report that their
workplace has a smoke-free policy. (BRFSS [1999],
Incidence CDC/NCHS)
• A survey conducted in 2002 found that an estimated 1.4 • The 2004 Health Consequences of Smoking Report of the
million Americans began smoking cigarettes daily in 2001. Surgeon General states that the risk of stroke decreases
This translates to close to 4,000 new regular smokers per steadily after smoking cessation. Former smokers have the
day, including more than 2,000 youths under age 18. same risk as nonsmokers after 5 to 15 years.
(National Survey on Drug Use and Health, samhsa.gov) (www.cdc.gov/tobacco/sgr/sgr_2004/Factsheets/3.htm)
• Information from the CDC Health Effects of Cigarette
Smoking Fact Sheet, February 2004:
9 Chewing Tobacco
• About 5 million American men and women use chewing
Prevalence of High School Students In Grades 9–12
Reporting Current Cigarette Smoking by Sex and
Race/Ethnicity
tobacco. (NHANES III [1988–94], CDC/NCHS)
YRBS: 2003
— Rates are highest in the South and rural areas.
— Men use chewing tobacco at 10 times the rate for 45
40
women. For men, the percentages who use chewing Males
tobacco are 6.8 for whites, 3.1 for blacks, 1.5 for 35
30 Females
Hispanics, 1.2 for Asian or Pacific Islanders and 7.8 for 26.6
American Indians or Alaska Natives. 25 23.3
19.3 19.1
20 17.7
— For women the percentages are 0.3 for whites, 2.9 for 15
blacks, 0.1 for Hispanics, almost none for Asian or Pacific 10.8
10
Islanders and 1.2 for American Indians or Alaska Natives. 5
— Use rates increase as years of education decrease for 0
both men and women.
Non-Hispanic Non-Hispanic Hispanics
Whites Blacks
Cost Source: MMWR, Vol. 53, (23); 499–502, June 18, 2004, CDC/NCHS.
• Direct medical costs and lost productivity costs associated

with smoking total an estimated $155 billion per year. Prevalence of Current Smoking for Americans Age 18
(CDC/NCHS) and older By Race/Ethnicity and Sex
NHIS: 2002
Non-Hispanic White
80 Non-Hispanic Black
Hispanic
70
Asian
60 American Indian or Alaska Native
50
40.5 40.9
40
30 25.5 27.1 22.7
19.0 21.8 18.7
20
10.8
10 6.5
0
Men Women
Source: MMWR, Vol. 53, (20); 427–431, May 28, 2004, CDC/NCHS.
High Blood Cholesterol and Other Lipids
Prevalence of Total Prevalence of Total Prevalence of LDL Prevalence of HDL
9
Cholesterol Cholesterol Cholesterol Cholesterol
200 mg/dL or higher 240 mg/dL or higher 130 mg/dL or higher less than 40 mg/dL
Population Group 2002 2002 2002 2002
Total population* 106,900,000 (50.7%) 37,700,000 (18.3%) 95,000,000 (45.8%) 54,700,000 (26.4%)
Total males* 50,400,000 (50.4%) 16,900,000 (17.2%) 48,600,000 (48.5%) 39,000,000 (39.0%)
Total females* 56,500,000 (50.9%) 20,800,000 (19.1%) 46,400,000 (43.3%) 15,900,000 (14.9%)
White males** 51.0% 17.8% 49.6% 40.5%
White females** 53.6% 19.9% 43.7% 14.5%
Black males** 37.3% 10.6% 46.3% 24.3%
Black females** 46.4% 17.7% 41.6% 13.0%
Mexican-American males 54.3% 17.8% 43.6% 40.1%
Mexican-American females 44.7% 13.9% 41.6% 18.4%
Total Hispanics #
— 25.6% — —
Total Asian or Pacific — 27.3% — —
Islanders#
Total American Indians or — 26.0% — —
Alaska Natives, Alaska#
Alaska Natives,
Oklahoma#
Alaska Natives,
Washington#
Note: mg/dL = milligrams per deciliter of blood. Prevalence of Total Cholesterol 200 mg/dL or higher includes people with total cholesterol of 240 mg/dL or higher. In
adults, levels of 200–239 mg/dL are considered borderline-high risk. Levels of 240 mg/dL or higher are considered high risk.
* Total population data for total cholesterol are for Americans age 20 and older. Data for LDL cholesterol, HDL cholesterol and all racial/ethnic groups are
age-adjusted for age 20 and older.
** Data for 240 mg/dL for whites are white only and for blacks are black or African-American only.
#
BRFSS (1997), MMWR, Vol. 49, No. SS-2, March 24, 2000, CDC/NCHS; data are for Americans age 18 and older.
Source for total cholesterol 200 mg/dL or higher: NHANES (1999 to 2000), Circulation. 2003;107:2185–2189; 240 mg/dL or higher data from Health, United
States, 2003, CDC/NCHS; LDL and HDL cholesterol: NHANES III (1988–94), CDC/NCHS.
• Among children and adolescents ages 4–19, the mean total

Prevalence blood cholesterol level is 165 mg/dL. For boys it’s 163
For information on dietary cholesterol, total fat, saturated fat and mg/dL and for girls it’s 167 mg/dL. The racial/ethnic
other factors that affect blood cholesterol levels, see Nutrition, breakdown is (NHANES III [1988–94], CDC/NCHS):
pages 46–47. — For non-Hispanic whites, 162 mg/dL for boys and 166
mg/dL for girls.
Youth — For non-Hispanic blacks, 168 mg/dL for boys and 171
• Among children and adolescents ages 4–19 years mg/dL for girls.
(NHANES III [1988–94], CDC/NCHS): — For Mexican Americans, 163 mg/dL for boys and 165
— Females have significantly higher average total mg/dL for girls.
cholesterol and low-density lipoprotein (LDL) • About 10 percent of adolescents ages 12–19 have total
cholesterol (bad cholesterol) than do males. cholesterol levels exceeding 200 mg/dL. (NHANES III
— Non-Hispanic black children and adolescents have [1988–94], CDC/NCHS)
significantly higher mean total cholesterol, LDL (bad)
Adults
cholesterol and HDL (good) cholesterol levels when
compared with non-Hispanic white and Mexican- • Beginning at age 45, a higher percentage of women than
American children and adolescents. men have total blood cholesterol of 200 mg/dL or higher.
(NHANES [1999–2000], CDC/NCHS)
• The prevalence of cholesterol screening during the — Among non-Hispanic whites, 91 mg/dL for boys and
9 preceding 5 years increased from 67.3 percent in 1991 to
70.8 percent in 1999. The age-standardized prevalence of
high blood cholesterol awareness among persons screened
100 mg/dL for girls.
— Among non-Hispanic blacks, 99 mg/dL for boys and
increased from 25.7 percent in 1991 to 28.6 percent in 1999.
— Among Mexican Americans, 93 mg/dL for boys and 92
(BRFSS, MMWR, Vol. 50, No. 35, Sept. 7, 2001, CDC/NCHS)
mg/dL for girls.
• A 10-percent decrease in total cholesterol levels (population-
wide) may result in an estimated 30-percent reduction in the Adults
incidence of CHD. (MMWR, Vol. 49, No. 33, Aug. 25, 2000,
CDC/NCHS) • The mean level of LDL cholesterol for American adults age
20 and older is 127 mg/dL. Levels of 130–159 mg/dL are
considered borderline high. Levels of 160–189 mg/dL are
Adherence classified as high, and levels of 190 mg/dL and higher are
Based on data from the Third Report of the Expert Panel on very high. (NHANES III [1988–94], CDC/NCHS)
Detection, Evaluation, and Treatment of High Blood Cholesterol — Among non-Hispanic whites, 20.4 percent of men and
in Adults (Adult Treatment Panel III [ATP III], NHLBI): 17.0 percent of women have an LDL cholesterol level of
160 mg/dL or higher.
• Less than half of persons who qualify for any kind of lipid-
modifying treatment for CHD risk reduction are receiving it. — Among non-Hispanic blacks, 19.3 percent of men and
18.8 percent of women have an LDL cholesterol level of
• Less than half of even the highest-risk persons, those who 160 mg/dL or higher.
have symptomatic CHD, are receiving lipid-lowering treatment. — Among Mexican Americans, 16.9 percent of men and
• Only about a third of treated patients are achieving their 14.0 percent of women have an LDL cholesterol level of
LDL goal; less than 20 percent of CHD patients are at their 160 mg/dL or higher.
LDL goal.
• Only about half of the people who are prescribed a lipid- HDL (Good) Cholesterol
lowering drug are still taking it six months later; after 12
The higher a person’s HDL cholesterol level is, the better. Less
months this falls to 30–40 percent. This is especially
than 40 mg/dL in adults is low HDL cholesterol, a risk factor for
troubling, because it takes six months to one year before a
heart disease and stroke.
benefit from treatment becomes apparent.
Trends in Mean Total Blood Cholesterol Among Youth
Adolescents Ages 12–17 by Race, Sex and Survey
NHES III: 1966–70, NHANES I & III: 1971–74, 1988–94 • Mean HDL cholesterol levels among children and
adolescents ages 4–19 are (NHANES III [1988–94],
174 CDC/NCHS):
Mean Total Blood Cholesterol
175 172
171 — Among non-Hispanic whites, 48 mg/dL for boys and 50
170
170 168
mg/dL for girls.
165 166 166
165 163 163 163 — Among non-Hispanic blacks, 55 mg/dL for boys and 56
mg/dL for girls.
160
155 — Among Mexican Americans, 51 mg/dL for boys and 52
150
Adults
0
White Black White Black • The mean level of HDL cholesterol for American adults age
Males Males Females Females 20 and older is 50.7 mg/dL. (NHANES III [1988–94],
CDC/NCHS)
NHES III NHANES I NHANES III
• Men and women who have low HDL cholesterol and high
total cholesterol levels have the highest risk of heart attack.
Source: CDC/NCHS. Prev Med. 1998;27:879–890. However, men with HDL levels of 37 mg/dL or lower or
women whose levels are 47 mg/dL or lower are at a high
LDL (Bad) Cholesterol risk regardless of their total cholesterol level. Conversely,
those with high levels of total cholesterol have lower risks of
Youth heart attack when they also have higher levels of HDL
cholesterol (53 mg/dL or greater in men and 67 mg/dL or
• Mean LDL cholesterol levels among children and adolescents greater in women). (FHS, NHLBI)
ages 12–19 are (NHANES III [1988–94], CDC/NCHS):
greater decline in activity for white girls at both younger
Physical Inactivity
Prevalence
and older ages. For black girls, this association is seen
only at the older ages. 9
Population Group 1999–2001 — Cigarette smoking is associated with decline in activity
among white girls. Pregnancy is associated with decline
Total Population 38.6%
in activity among black girls but not among white girls.
Total Males 35.8%
— A higher BMI is associated with greater decline in
Total Females 41.0% activity among girls of both races.
White only males 34.4%
Adults
White only females 38.3%
Prevalences of no leisure-time physical activity by race and sex, in
Black or African-American males 45.1%
adults age 18 and older: (BRFSS [2002], MMWR, Vol. 53, No. 4,
Black or African-American females 55.1% Feb. 6, 2004, CDC/NCHS)
American Indian or Alaska Native only males 42.5%
Population Group Men Women
American Indian or Alaska Native only females 55.5%
Non-Hispanic whites 19.2 23.2
Hispanic or Latino males 52.6%
Non-Hispanic blacks 27.7 36.0
Hispanic or Latino females 57.2%
Hispanics 35.2 40.1
Asian only males 33.4%
Asian or Pacific Islanders 19.9 28.0
Asian only females 42.6%
American Indians or Alaska Natives 26.3 29.8
Native Hawaiian or other Pacific Islander males 38.5%
Native Hawaiian or other Pacific Islander females 27.1% • 2001–2003 data from the BRFSS study of the CDC/NCHS
showed that among Asians and Native Hawaiian or Other
Pacific Islanders, 21.2 percent of men and 27.0 percent of
Note: Prevalence is the percentage of population who report no
women reported no leisure-time physical activity. Of these,
leisure-time physical activity.
21.5 percent were overweight (BMI 25.0–29.9) and 23.8
Source: NHIS (1999–2001), CDC/NCHS; data are age-adjusted for
were obese (BMI 30.0 and over). (MMWR, Vol. 53, No. 33;
Americans age 18 and older.
756–760, August 27, 2004)
• Based on data from the 1999–2001 NHIS survey of the
CDC/NCHS… (Vital and Health Statistics, Series 10, No.
Prevalence 219, Feb. 2004)
— 31.3 percent of U.S. adults age 18 and older engage in
Youth any regular leisure-time physical activity (PA).
• In 2003, 58.5 percent of male and 52.8 percent of female — Men (64.2 percent) were more likely than women (59.0
high school students, grades 9–12, were enrolled in percent) to engage in at least some leisure-time PA.
physical education (PE) classes. 30.5 percent of males and — Engaging in any PA declined steadily with age from
26.4 percent of females attended classes daily and 84.5 39.7 percent of adults ages 18–24 to 15.6 percent age 75
percent of males and 75.3 percent of females exercised or and older.
played sports during an average PE class. (MMWR, Vol. — Engaging in any regular leisure-time PA was more
53, No. SS-2, May 21, 2004, CDC/NCHS) prevalent among white adults (32.7 percent) than among
• 2002 data from the Youth Media Campaign Longitudinal Asian adults (27.8 percent) and black adults
Study (YMCLS) of the CDC showed that 61.5 percent of (23.9 percent).
children ages 9–13 don’t participate in any organized — Non-Hispanic white adults (65.7 percent) were more
physical activity (PA) during their nonschool hours and likely than non-Hispanic black adults (49.3 percent) and
that 22.6 percent don’t engage in any free-time PA. Non- Hispanic adults (45.0 percent) to engage in at least some
Hispanic black and Hispanic children are significantly less leisure-time PA.
likely than non-Hispanic white children to report — Adults with a graduate degree (80.6 percent) were about
involvement in organized activities, as are children with twice as likely as adults with less than a high school
parents who have lower incomes and education levels. diploma (41.0 percent) to engage in at least some
(MMWR, Vol. 52, No. 33, Aug. 22, 2003, CDC/NCHS) leisure-time PA.
• By the age of 16 or 17, 31 percent of white girls and 56 — Adults who had incomes four times the poverty level or
percent of black girls report no habitual leisure-time more (39.9 percent) were about twice as likely as adults
activity. (NEJM 2002;347:709–15) with incomes below the poverty level (22.6 percent) to
— Lower levels of parental education are associated with engage in any regular PA.
— Widowed adults (23.6 percent) were less likely than
never-married adults (33.0 percent), married adults (31.1 Prevalence of Students in Grades 9–12 Who Participated
9 percent), and divorced or separated adults (29.1 percent)

to engage in regular PA.
in Sufficient Vigorous or Moderate Physical Activity
During the Past 7 Days by Race/Ethnicity and Sex
YRBS: 2003
— Adults living in the West (65.3 percent) were more
likely than adults living in the South (56.4 percent) to 80
71.9
engage in at least some leisure-time PA. 70 66.7
65.0
58.1
• The relative risk of CHD associated with physical inactivity 60 51.8
ranges from 1.5 to 2.4, an increase in risk comparable to 50 44.9
that observed for high blood cholesterol, high blood pressure 40
or cigarette smoking. (JAMA 1995;273:402–7) 30 28.9 25.8
23.3 23.3
• A recent study of over 72,000 female nurses indicates that 20.6
20 17.5
moderate-intensity physical activity such as walking is
10
associated with a substantial reduction in risk of total and
ischemic stroke. (JAMA 2000;283:2961–7) 0
Non-Hispanic Non-Hispanic Non-Hispanic Non-Hispanic Hispanic Hispanic
White White Black Black Males Females
• The prevalence of physical inactivity during leisure time Males Females Males Females
among Mexican Americans is higher than in the general
population. (NHANES III [1988–94], CDC/NCHS, Am J Vigorous Moderate
Public Health 2001;91:1254–7)
— The prevalence of physical inactivity among those Note: “Vigorous activity” is defined as activity causing sweating and
whose main language is English is 15 percent of men hard breathing for at least 20 minutes on 3 or more of the 7
and 28 percent of women. This is similar to that of the days. “Moderate activity” is defined as activities such as
general population (17 percent of men and 27 percent walking or bicycling lasting for at least 30 minutes on 5 or
of women). more of the 7 days.
— Those whose main language is Spanish have the highest Source: MMWR, Vol. 53, No. SS-2, May 21, 2004, CDC/NCHS.
prevalence of physical inactivity (38 percent of men and
58 percent of women). Prevalence of Moderate or Vigorous Physical Activity in
Americans Age 20 and Older by Race/Ethnicity, Sex,
Cost and BMI
NHANES III: 1988–94
• The annual estimated cost for diseases associated with
physical inactivity in 2000 was $76 billion. (CDC) 50 48.8 47.3 44.5
46.6 41.8 44.2
39.5
40 37.3 35.4 30.3
30.6 29.4 29.5
30 26.4
28.8 26.8 28.7
20.0
20
10
0
Non-Hispanic Non-Hispanic Mexican- Non-Hispanic Non-Hispanic Mexican-
White Black American White Black American
Men Men Men Women Women Women
BMI <25 BMI 25-29.9 BMI 30+
Note: BMI indicates body mass index: weight in kilograms divided

by height in meters squared (kg/m2).
Source: CDC/NCHS.
— Among preschool children, the following are
Overweight and Obesity
Prevalence of Prevalence of Prevalence of

overweight: 8.6 percent of non-Hispanic whites, 8.8
percent of non-Hispanic blacks and 13.1 percent of
Mexican Americans.
9
Overweight Overweight Overweight Prevalence
— Among children ages 6–11, the following are
in Children in Adolescents and Obesity of Obesity
Population Ages 6–11 Ages 12–19 in Adults in Adults
Group 2002 2002 2002 2002
Mexican Americans.
Total population 3,890,000 5,290,000 134,750,000 63,120,000
(15.8%) (16.1%) (65.1%) (30.4%) — Among adolescents ages 12–19, the following are
Total males 2,130,000 2,820,000 68,590,000 27,480,000
(16.9%) (16.7%) (68.8%) (27.6%)
Mexican Americans.
Total females 1,760,000 2,470,000 66,160,000 35,640,000
(14.7%) (15.4%) (61.6%) (33.2%) — In addition, the data show that another 31 percent of
White males 14.0% 14.6% 69.4% 28.2%
children and teens ages 6 to 19 are considered at risk of
becoming overweight (BMI from the 85th to the 95th
White females 13.1% 12.7% 57.2% 30.7%
percentile).
Black males 17.0% 18.7% 62.9% 27.9%
Black females 22.8% 23.6% 77.2% 49.0% Adults
Mexican
• The age-adjusted prevalence of overweight (BMI of 25.0 or
American males 26.5% 24.7% 73.1% 27.3%
higher) increased from 55.9 percent in NHANES III
Mexican
(1988–94) to 65.1 percent in NHANES (1999–2002). The
American females 17.1% 19.9% 71.7% 38.4%
prevalence of obesity (BMI of 30.0 or higher) also increased
Hispanics or Latinos* — — 65.2% 25.4% during this period from 22.9 percent to 30.4 percent.
Asians* — — 34.5% 7.0% Extreme obesity (BMI of 40.0 or higher) increased from 2.9
American Indians or percent to 4.9 percent. (JAMA 2004;291:2847–50)
Alaska Natives* — — 61.7% 31.3% • Since 1991 the prevalence of those who are obese increased
75 percent. Among states in 2001, Mississippi had the
Note: BMI (body mass index) = weight in kilograms divided by height in highest rate of obesity and Colorado had the lowest.
meters squared (kg/m2). (BRFSS, CDC/NCHS)
Data for white, black or African-American, and Asian or Pacific
• Data from the BRFSS study of the CDC/NCHS showed that
Islander males and females are for non-Hispanics.
in participants ages 18–24, studied from 1990–2000, obesity
Overweight in adults is BMI 25 and higher. Obesity in adults is BMI increased among every ethnic group, especially in black
30.0 or higher. Overweight in children is BMI 95th percentile or higher women. Almost 20 percent of black women were obese by
of the CDC 2000 growth chart. ages 18–24, increasing to over 35 percent by ages 25–44.
* NHIS (2002), CDC/NCHS; data are for Americans age 18 and older. Between one-third and one-half of those surveyed ate fewer
than three servings of fruit and vegetables a day, although
Sources: NHANES (1999–2002), (JAMA. 2004;291:2847–50); CDC/NCHS older black men and older Hispanic men and women
data in adults are for age 20 and older. Data are for non- improved dramatically in that regard between 1990 and
Hispanics.
2000. (Am J Health Promot 2004;19(1):19)
• Abdominal obesity is an independent risk factor for
Prevalence ischemic stroke in all race ethnic groups with an odds ratio
about 3 times greater when comparing the first and fourth
Youth quartiles. This effect was larger for those under age 65
(OR=4.4) than over age 65 (OR=2.2). (NOMASS) (Stroke
• An estimated 9,180,000 children and adolescents ages 6–19 2003;34:1586–92)
are considered overweight or obese, based on the 95th • Among American Indians or Alaska Natives, single-race
percentile or higher of body mass index (BMI) values in the adults, age 18 and older, the following are overweight or
2000 CDC growth chart for the United States. (NHANES obese: (NHIS [1999–2001], CDC/NCHS, Vital and Health
[1999–2002], CDC/NCHS) Statistics, Series 10, No. 219, Feb. 2004)
• Based on data from NHANES (1999–2002), the prevalence — 76.6 percent of men and 61.1 percent of women are
of overweight in children ages 6–11 increased from 4.2 overweight (BMI of 25 or more).
percent to 15.8 percent compared with data from 1963–65.
The prevalence of overweight in adolescents ages 12–19 — Overall, 34.6 percent are overweight but not obese and
increased from 4.6 percent to 16.1 percent. (CDC/NCHS) 34.2 percent are obese. Among these, 38.0 and 38.6
percent respectively were men and 31.3 and 29.7 percent
• Over 10 percent of preschool children between the ages of 2 respectively were women.
and 5 are overweight, up from 7 percent in 1994. (NHANES
[1999–2002], CDC/NCHS; JAMA 2004;291:2847–50)
• A recent comparison of risk factors in both the HHP and Prevalence of Overweight Among Students in Grades
9 FHS showed a BMI increase around 3 kg/m2 raised the risk

of hospitalized thromboembolic stroke by 10–30 percent.
(Stroke 2002;33:230–7)
9–12 by Sex and Race/Ethnicity
YRBS: 2003
• In 1998–99, surveys of people in 8 states and the District of Non-Hispanic Whites

Columbia by the BRFSS study of the CDC/NCHS indicated Non-Hispanic Blacks
that obesity rates are significantly higher among people with 25 Hispanics
21.7
disabilities, especially blacks and those ages 45–64. 19.5
20
(MMWR, Vol. 51, No. 36, Sept. 13, 2002, CDC/NCHS)
16.2 15.6
• Data from the FHS showed that overweight and obesity 15
were associated with large decreases in life expectancy. 11.8
Forty-year-old female nonsmokers lost 3.3 years and 40- 10
7.8
year-old male nonsmokers lost 3.1 years of life expectancy
because of overweight. In 40-year-old nonsmokers, females 5
lost 7.1 years and males lost 5.8 years due to obesity.
Obese female smokers lost 7.2 years and obese male
0
Males Females
smokers lost 6.7 years when compared to normal-weight
nonsmokers. (Ann Intern Med 2003;138:24–32)
Source: BMI 95th percentile or higher by age and sex of the CDC 2000
growth chart. MMWR, Vol. 53, No. SS-2, May 21, 2004,
Mortality CDC/NCHS.
• Each year an estimated 300,000 U.S. adults die of causes
related to obesity. (JAMA 1999;282:1530–8)
Age-Adjusted Prevalence of Obesity in Americans Ages
• Obesity profoundly affects life span. A 20-year-old white 20–74 by Sex and Survey
male with a BMI greater than 45 is estimated to have 13 NHES 1960–62; NHANES: 1971–74, 1976–80, 1988–94
years of life lost (YLL) due to obesity. A 20-year-old white and 1999–2002
woman with a BMI greater than 45 is estimated to have 8
33.2
YLL due to obesity. For black men the estimate is 20 YLL 35
and for black women the estimate is 5 YLL. (JAMA
30 27.6
25.9
2003;289:187–93)
25
20.6
20 17.0
Cost 15.8 16.6
15 12.1 12.7
10.7
• Nationally, the estimated annual cost attributable to obesity- 10
related diseases is about $100 billion. (MMWR, Vol. 51, No.
36, Sept. 13, 2002, CDC/NCHS) 5
• Among children and adolescents, annual hospital costs 0
Men Women
related to obesity were $127 million during 1997–99.
(CDC) (“Preventing Obesity and Chronic Diseases Through 1971–74 1976–80
1960–62
good Nutrition and Physical Activity,”
www.cdc.gov/nccdphp/pe_factsheets) 1988–94 1999–2002
Note: Obesity is defined as a BMI of 30.0 or higher.
Source: CDC/NCHS.
Diabetes Mellitus
(ICD/9 250) (ICD/10 E10–E14) 9
Prevalence of Prevalence of Prevalence of Incidence of Hospital
Population Physician-Diagnosed Undiagnosed Pre-Diabetes Diagnosed Mortality Discharges
Group Diabetes — 2002 Diabetes — 2002 2002 Diabetes 2002 2002
Total population 13,900,000 (6.7%) 5,900,000 (2.8%) 14,500,000 (7.0%) 1,300,000 73,249 577,000
Total males 6,800,000 (7.2%) 2,900,000 (2.9%) 8,500,000 (8.9%) — 34,301 (46.8%)* 283,000
Total females 7,000,000 (6.3%) 3,000,000 (2.7%) 6,000,000 (5.4%) — 38,948 (53.2%)* 294,000
White males 6.2% 3.0% 8.6% — 28,110 —
White females 4.7% 2.7% 4.6% — 30,349 —
Black males 10.3% 1.3% 8.3% — 5,207 —
Black females 12.6% 6.1% 5.9% — 7,480 —
Mexican-American males 10.4% 3.5% 8.7% — — —
Mexican-American females 11.3% 1.8% 7.2% — — —
Hispanics or Latinos** 9.4% — — — — —
Asians** 6.3% — — — — —
American Indians or Alaska Natives** 16.0% — — — — —
Note: Undiagnosed diabetes is defined here for those whose fasting glucose is 126 mg/dL or higher but who did not report being told they
had diabetes by a health care provider. Pre-diabetes is a fasting blood glucose of 100 to less than 126 mg/dL (impaired fasting
glucose). Pre-diabetes also includes impaired glucose tolerance.
* These percentages represent the portion of total mortality that is males vs. females.
** NHIS (2002), CDC/NCHS; data are for Americans age 18 and older.
Sources: Prevalence: NHANES [1999–2002], CDC/NCHS and NHLBI; data for white and black males and females are for non-Hispanics; percentages for
racial/ethnic groups are age-adjusted for Americans age 20 and older. Incidence: NIDDK estimates. Mortality: CDC/NCHS; data for white and
black males and females include Hispanics. Hospital discharges: CDC/NCHS; data include people both living and dead.
• Data from the NHANES (1999–2000) study of the

Prevalence CDC/NCHS showed a disproportionately high prevalence of
• The prevalence of diabetes increased by 8.2 percent from diabetes in non-Hispanic blacks and Mexican Americans
2000 to 2001. Since 1990 the prevalence of those diagnosed when compared to non-Hispanic whites. For previously
with diabetes increased 61 percent. In 2001 Alabama had the diagnosed diabetes the percentage was 11.7 for non-
highest rate of diagnosed diabetes (10.5 percent) and Hispanic blacks and 9.6 for Mexican Americans compared
Minnesota had the lowest (5.0 percent). (JAMA to 4.8 for non-Hispanic whites. For undiagnosed diabetes
2003;289:76–9) the percentages were 3.2, 2.4 and 2.6, respectively. For
• During 1994–2002 the age-adjusted prevalence of diabetes impaired fasting glucose the percentages were 6.3, 6.7 and
increased 54.0 percent for U.S. adults, from 4.8 to 7.3 5.7, respectively. (MMWR, Vol. 52(35);833–7, CDC/NCHS)
percent, and increased 33.2 percent from 11.5 to 15.3 • In the NHANES III study of the CDC/NCHS, prevalence in
percent among American Indian or Alaska Native adults. Hispanic Americans ages 40 to 74, the rate was 11.2 percent
The overall age-adjusted prevalence for American Indian or for non-Hispanic whites, but 20.3 percent for Mexican
Alaska Native adults was more than twice that of U.S. adults Americans. (niddk.nih.gov, 2004)
overall. (MMWR, Vol. 52, No. 30, Aug. 1, 2003, • BRFSS data in selected areas, 1998–2002, showed that
CDC/NCHS) diabetes disproportionately affects Hispanics in the U.S. and
• Based on data from the NHANES studies of the Puerto Rico. Hispanics were twice as likely to have diabetes
CDC/NCHS, in 1976–80, total diabetes prevalence in as non-Hispanic whites of similar age (9.8 percent vs. 5.0
African Americans ages 40 to 74 was 8.9 percent; in percent). This disparity, however, varied by geographic
1988–94 the rate was 18.2 percent, a doubling of the rate in location — it was lowest in Florida and higher in California,
just 12 years. In 1988–94 among people ages 40 to 74, the Texas, and Puerto Rico. Among Hispanic adults in
prevalence rate was 18.2 percent for African Americans California, Florida, Illinois, New York/New Jersey, Puerto
compared to 11.2 percent for whites. (Diabetes Care Rico and Texas, the overall prevalence of diabetes was 7.4
1998;21:518–24) percent; it ranged from 6.2 percent in Illinois and New
York/New Jersey to 9.3 percent in Puerto Rico. (MMWR
2004;53(40):941–4)
• About 15 percent of American Indians or Alaska Natives • Heart disease death rates among adults with diabetes are 2
9 who receive care from the Indian Health Service have been
diagnosed with diabetes. On average, American Indians or
Alaska Natives are 2.6 times as likely to have diagnosed
to 4 times higher than the rates for adults without diabetes.
(diabetes.niddk.nih.gov)
• Death rates for people with diabetes are 27 percent higher
diabetes as non-Hispanic whites of the same age. for African Americans compared with whites.
(niddk.nih.gov, 2004) (niddk.nih.gov, 2004)
• The prevalence of diabetes for all age groups worldwide was
estimated to be 2.8 percent in 2000 and a projected 4.4 Aftermath
percent in 2030. The total number of people with diabetes is
• The age-adjusted prevalence of major CVD for women with
projected to rise from 171 million in 2000 to 366 million in
diabetes is twice that for women without diabetes, and the
2030. [Diabetes Care 2004;27(5)]
age-adjusted major CVD hospital discharge rate for women
• Type 2 diabetes may account for 90 to 95 percent of all with diabetes is almost four times the rate for women
diagnosed cases of diabetes. (niddk.nih.gov, 2004) without diabetes. (MMWR, Vol. 50, No. 43, Nov. 2, 2001,
• In April 2004, the USDHHS announced that about 40 CDC/NCHS)
percent of U.S. adults ages 40–74, or 41 million, currently • A population-based study of over 13,000 men and women in
have pre-diabetes, a condition that raises a person’s risk of Denmark showed that in people with type 2 diabetes, the
developing type 2 diabetes, heart disease and stroke. Many relative risk (RR) of first, incident and admission for MI was
don’t know that they are at risk or that they have pre- increased 1.5–4.5 fold in women and 1.5–2 fold in men. The
diabetes. (National Diabetes Education Program, May 2004 RR of first, incident and admission for stroke was increased
E-Newsletter). 2–6.5 fold in women and 1.5–2 fold in men, with a
• In the U.S. each year, over 13,000 children are diagnosed significant difference between the sexes. In both men and
with type 1 diabetes. Increasingly, healthcare providers are women the RR of death was increased 1.5–2 times. (Arch
finding more and more children and teens with type 2 Intern Med 2004;164:1422–6)
diabetes. Some clinics report that one-third to one-half of all • Diabetes increases the risk of stroke, with the RR ranging
new cases of childhood diabetes are now type 2. African from 1.8 to almost 6.0. (Stroke 2001;32:280–99)
American, Hispanic or Latino and American Indian children
• Diabetes is one of the most important risk factors for stroke
who are obese and have a family history of type 2 diabetes
in women. In the FHS and in several European studies, the
are at especially high risk for this type of diabetes.
impact of diabetes on stroke risk is greater in women than in
(niddk.nih.gov, 2004)
men. (Stroke 2001;32:280–99; Neuroepidemiology
• The risk of diabetes for Mexican Americans and non- 1999;18:1–14)
Hispanic blacks is almost twice that for non-Hispanic
• Compared with white women, black women have a 138
whites. (NHANES III [1988–94], CDC/NCHS, Diabetes
percent higher rate of ambulatory medical care visits for
Care 1998;21:518–24)
diabetes. (Utilization of Ambulatory Medical Care by
• Analysis of data collected in Hawaii from 1996 to 2000 Women: United States, 1997–98. NCHS, 2001)
showed that Native Hawaiians were 2.5 times more likely to
• Based on data from the CDC Diabetes Surveillance System,
have diabetes than non-Hispanic white residents of similar
1997–2000:
age. (niddk.nih.gov, 2004)
— In 2000 the age-standardized prevalence of any self-
• Diabetes is twice as common in Mexican American and
reported CV condition among persons with diabetes age
Puerto Rican adults as in non-Hispanic whites. The
35 and older was 37.5 percent for white men, 32.2
prevalence of diabetes in Cuban Americans is lower, but still
percent for white women, 31.4 percent for black men,
higher than that of non-Hispanic whites.
34.0 percent for black women, 23.9 percent for Hispanic
(niddk.nih.gov, 2004)
men and 22.9 percent for Hispanic women.
— In 2000 the self-reported prevalence of any CV
Mortality condition was 28.8 per 100 diabetic population among
persons ages 35–64, 45.7 per 100 among persons ages
Total mention mortality — 218,100. 65–74, and 53.5 per 100 persons age 75 and older.
• The 2002 overall death rate from diabetes was 25.4. Death — In 2000, among persons with diabetes age 35 and older,
rates were 26.8 for white males, 49.4 for black males, 20.3 37.2 percent reported being diagnosed with a CV
for white females and 48.6 for black females. condition, (i.e., CHD, stroke or other CV condition).
• From two-thirds to three-fourths of people with diabetes — In 2000, among persons with diabetes age 35 and older,
mellitus die of some form of heart or blood vessel disease. the age-standardized prevalence of self-reported CHD,
angina or heart attack, was almost three times that of
self-reported stroke (22.1 percent vs. 8.0 percent).
— In 2000, 4.4 million persons age 35 and older with
diabetes reported being diagnosed with a CV condition.
2.9 million were diagnosed with CHD (i.e., self-reported
CHD, angina or heart attack) and 1.1 million reported
Age-Adjusted Prevalence of Physician-Diagnosed
Diabetes in Americans Age 20 and Older by Sex and
Race/Ethnicity
9
NHANES: 1999–2002
being diagnosed with a stroke.
Risk Non-Hispanic Whites

• Among U.S. adults with diabetes, data from the NHANES Non-Hispanic Blacks
surveys from 1971–74 to 1999–2000, showed that mean Mexican Americans 12.6
total cholesterol declined from 5.95 mmol/liter to 5.48 12 11.3
10.3 10.4
mmol/liter. The proportion with high cholesterol decreased 10
from 72 to 55 percent. Mean blood pressure declined from
146/86 mm Hg to 134/72 mm Hg. The proportion with HBP 8
6.2
decreased from 64 to 37 percent, and smoking prevalence 6 4.7
decreased from 32 to 17 percent. Although these trends are
encouraging, still one of two people with diabetes had high 4
cholesterol, one of three had HBP, and one of six was a 2
smoker. (Am J Epidemiol 2004;160:531–9)
• Data from the National Institute of Diabetes and Digestive 0
Men Women
and Kidney Diseases (NIDDK) of the NIH stated:
— Heart disease is the leading cause of diabetes-related
Source:CDC/NCHS and NHLBI.
death. Adults with diabetes have heart disease death
rates about 2 to 4 times higher than adults without
diabetes. Prevalence of Non-Insulin-Dependent (Type 2) Diabetes
— The risk for stroke is 2 to 4 times higher among people in Women* Ages 25–64 by Race/Ethnicity and Education
with diabetes. NHANES III: 1988–94
— About 73 percent of adults with diabetes have blood
pressure greater than or equal to 130/80 mm Hg or use 20.0
prescription medication for hypertension. 20 Whites
— An estimated 49–69 million adults in the United States Blacks

may have insulin resistance. (Personal communication 15
11.5 Mexican
with Earl Ford, MD, CDC/NCHS, 2003) One in four of 11.3
Americans
10 9.3
them will develop type 2 diabetes. (ndep.nih.gov)
6.8 6.1 6.4
5.4
4.5 4.6 5.1
Cost 5 2.9
• In 2002, the direct and indirect cost of diabetes was $132

0
billion. (The Burden of Chronic Diseases and Their Risk <9 9-11 12 >12
Factors, CDC/NCHS, Feb. 2004) Years of Education
* Findings for men are similar but of lower magnitude. See:

Pathways by which SES and ethnicity influence cardiovascular
disease risk factors. Annals New York Academy of Science.
1999;896:191–209.
Source: JAMA. 1998;280:356–362.
10 Metabolic Syndrome
The Third Report of the National Cholesterol Education Program — MetS was present in 28.7 percent of overweight
(NCEP) Expert Panel on Detection, Evaluation, and Treatment of adolescents (BMI ≥ 95th percentile of CDC Growth
High Blood Cholesterol in Adults (ATP III, NHLBI) defines the Chart) compared with 6.8 percent of at-risk of
metabolic syndrome (MetS) as three or more of the following overweight adolescents, and 0.1 percent of those with
abnormalities: BMI below the 85th percentile (P<.001).
• Waist circumference greater than 102 cm (40 inches) in men — Among adolescents with MetS, 40.9 percent had ≥ 1
and 88 cm (35 inches) in women. criterion; 14.2 percent had ≥ 2 criteria; 4.2 percent had ≥
3 criteria and 0.9 percent had ≥ 4 criteria for MetS. For
• Serum triglyceride level of 150 mg/dL or higher.
overweight adolescents, 88.5 percent had ≥ 1 criterion;
• High-density lipoprotein (HDL) cholesterol level less than 54.4 percent had ≥ 2 criteria; 28.7 percent had ≥ 3
40 mg/dL in men and less than 50 mg/dL in women. criteria and 5.8 percent had ≥ 4 criteria for MetS.
• Blood pressure of 130/85 mm Hg or higher. • Among more than 3,400 children examined in one study, 1
• Fasting glucose level of 110 mg/dL or higher. in 10 had the MetS. (De Ferranti, et al. Circulation
People with MetS are at increased risk for developing diabetes and 2003;108:17:IV-727, Meeting Abstract #3286)
cardiovascular disease as well as increased mortality from CVD • Using a sample of adolescents from NHANES III, the
and all causes. overall prevalence of the MetS in moderately obese subjects
was 38.7 percent and 49.7 percent in severely obese
subjects. The prevalence of the MetS in severely obese black
Prevalence of Metabolic subjects was 39 percent. (NEJM 2004;350:2362–74)
Syndrome Among Adolescents:
The prevalence of MetS among 12–19 year old U.S. adolescents Prevalence of Metabolic
was estimated in an analysis of NHANES III data, by applying a Syndrome Among Adults
modification of the ATP III definition for adults. MetS during
adolescence was defined as three or more of the following • An estimated 47 million U.S. residents have the MetS.
abnormalities: (NHANES III [1988–94], CDC/NCHS; JAMA
2002;287:356–9)
• Serum triglyceride level of 110 mg/dL or higher.
• The age-adjusted prevalence of the MetS for adults is 23.7
• High-density lipoprotein (HDL) cholesterol level of 40 percent. (NHANES III [1988–94], CDC/NCHS; JAMA
mg/dL or lower. 2002;287:356–9)
• Elevated fasting glucose of 110 mg/dL or higher. — The prevalence ranges from 6.7 percent among people
ages 20–29 to 43.5 percent for ages 60–69 and 42.0
• Blood pressure at or above the 90th percentile for age, sex percent for those age 70 and older.
and height.
— The age-adjusted prevalence is similar for men (24.0
• Waist circumference at or above the 90th percentile for age percent) and women (23.4 percent).
and sex (NHANES III data set) — Mexican Americans have the highest age-adjusted
An estimated 1 million 12–19 year old adolescents in the U.S. prevalence of the MetS (31.9 percent). The lowest
have the MetS, or 4.2 percent overall (6.1 percent of males; 2.1 prevalence is among whites (23.8 percent), African
percent of females). [Cook S, et al. Arch Pediatr Adol Med Americans (21.6 percent) and people reporting an
2003;157:821–7] “other” race or ethnicity (20.3 percent).
— Among African Americans, women had about a 57
• Of adolescents with MetS, 73.9 percent were overweight
percent higher prevalence than men. Among Mexican
(BMI ≥ 95th percentile of the CDC Growth Chart), and 25.2
Americans, women had a 26 percent higher prevalence
percent were at risk of overweight (BMI 85–94th percentile).
than men did.
• The mean BMI of adolescents with the MetS (30.1 percent)
• The prevalences of people with the MetS are 24.3, 13.9 and
was just above the 95th percentile of the CDC Growth
20.8 percent for white, black and Mexican-American men,
Chart; thus they are likely to represent a fairly common
respectively. For women the percents are 22.9, 20.9 and
clinical problem in pediatrics.
27.2, respectively. (NHANES III [1988–94], CDC/NCHS;
Arch Intern Med 2003;163)
• In a study of over 15,000 men and women, ages 45 to 64,
Total Mortality Rates in U.S. Adults, Ages 30–75, With
Metabolic Syndrome (MetS), With and Without Diabetes
Mellitus (DM) and Pre-Existing CVD
10
in the ARIC study, MetS prevalence was 30 percent and 27 NHANES II 1976–80 Follow-Up Study*
percent using ATP III and modified WHO definitions with
substantial variation across race and gender subgroups. 50
45 No MetS or DM DM only 44.1
Deaths/1,000 Person Years

CHD prevalence was greater in those with than without the
MetS w/o DM Prior CVD
MetS (ATP III 7.4 percent vs. 3.6 percent; WHO 7.8 40
percent vs. 3.6 percent, both p<0.0001). Using either MetS w/DM Prior CVD and DM
35
definition, subjects with the MetS were about two times 30.0
30 28.1 26.1
more likely to have prevalent CHD than those without the 25 21.1
syndrome after adjustment for established risk factors. 17.1
20 17.0 16.7
Among individuals free of CVD, the average age, sex, and 14.4
race/center-adjusted intima-media thickness (IMT) was 15 11.5
10.9 8.6
10 7.8
greater among individuals with the syndrome [ATP III 747 6.3 5.3
4.8
vs. 704, WHO 750 vs. 705 micrometers, both p<0.0001]. 5 2.6 4.3
These data suggest that MetS was significantly associated 0
CHD Mortality CVD Mortality Total Mortality
with the presence of CHD and carotid IMT. (Am J Cardiol
2004;94:1249–54)
• A follow-up study of over 19,000 men found that those Source: Circulation 2004;110:1245–50.
with the MetS who were fit were less likely to die during * Average of 13 years of follow-up.
the study. The total person-years of follow-up is over
190,000. Those who were deemed to be out of shape were
twice as likely as those who were fit to die of CVD or any
other cause. An additional study of 2,200 diabetic men
found that those who were overweight yet fit had a risk
similar to that of their fit, healthy peers. They estimated
that moderate exercise, such as walking for 30 minutes five
times per week, would be enough to achieve protective
fitness levels. (Arch Intern Med 2004;164:1092–7)
11 Nutrition
Mean Dietary Intake of Energy and Total • The average daily intake of total fat in the United States is
10 Key Nutrients for Public Health Population Males Females 81.4 grams (96.5 g for males and 67.3 g for females).
Energy (kcal) 2,146 2,475 1,833 (NHANES III [1988–94], CDC/NCHS)
Protein, percent of calories 14.7% 14.9% 14.6% — For non-Hispanic whites the average is 82.7 grams
Carbohydrate, percent of calories 51.9% 50.9% 52.8% (99.0 g for males and 67.4 g for females).
Total fat, percent of calories 32.7% 32.7% 32.6% — For non-Hispanic blacks the average is 82.0 grams
Saturated fat, percent of calories 11.2% 11.2% 11.1% (94.6 g for males and 71.2 g for females).
Cholesterol (mg) 265 307 225
— For Mexican Americans the average is 77.6 grams
Calcium (mg) 863 966 765
(88.0 g for males and 66.5 g for females).
Folate micrograms (mcg) 361 405 319
• The average daily intake of saturated fat in the United States
Iron (mg) 15.2 17.2 13.4
is 27.9 grams (33.1 g for males and 23.0 g for females).
Zinc (mg) 11.4 13.3 9.7
(NHANES III [1988–94], CDC/NCHS)
Sodium (mg) 3,375 3,877 2,896
— For non-Hispanic whites the average is 28.4 grams
Source: NHANES (1999–2000), CDC/NCHS, 2003. (Advance Data, Vital (34.1 g for males and 23.1 g for females).
and Health Statistics, No. 334, April 17, 2003. ) — For non-Hispanic blacks the average is 27.5 grams
• The Economic Research Service of the USDA suggests that
— For Mexican Americans the average is 26.7 grams
the average daily calorie consumption in the United States in
2000 was 12 percent, or roughly 300 calories, above the
1985 level. Of that increase, grains (mainly refined grains) • The proportion of fat calories from beef, pork, dairy
accounted for 46 percent, added fats 24 percent, added products and eggs fell from 50 percent in 1965 to 33 percent
sugars 23 percent, fruits and vegetables 8 percent, and the in 1994–96. The proportion of fat calories from poultry
meat and dairy groups together declined 1 percent. Per increased from 4 percent to 7 percent. Calories from fruits
capita availability of total dietary fat, after remaining steady and vegetables rose from 8 percent to 13 percent. (Prev Med
from 1985 to 1999, jumped 6 percent in 2000. American 2001;32:245–54)
diets are also low in whole grains and other nutritious foods. • In 1994–96, pizza, Mexican food, Chinese food,
(ers.usda.gov/briefing/consumption) hamburgers, French fries and cheeseburgers accounted for
• Between 1965 and 1991 among U.S. adults age 18 and 10.8 percent of total fat intake. These six foods accounted
older, total daily calories declined from 2,049 to 1,807, but for only 1.9 percent of fat intake in 1965. (Prev Med
then rebounded to 2,000 calories in 1996. This contributed 2001;32:245–54)
to the marked increase in obesity levels in the past decade. • The major sources of saturated fat in the diet are red meat,
(Prev Med 2001;32:245–54) butter, whole milk and eggs. Intake of these foods has fallen
• In 1999–2000, among children ages 2 to 6, 20 percent had a markedly since 1965. The decline in whole milk
good diet, 74 percent had a diet that needed improvement, consumption from 21.3 gallons in 1972–76 to 8.2 gallons in
and 6 percent had a poor diet. For those ages 7 to 12, 8 1997 accounts for most of the reduction in saturated fat.
percent had a good diet, 79 percent had a diet that needed (Prev Med 2001;32:245–54)
improvement, and 13 percent had a poor diet. (America’s • According to USDA data, in 2001 total meat consumption
Children: Key National Indicators of Well-Being, 2003. (red meat, poultry and fish) amounted to 194 pounds per
Federal Interagency Forum on Child and Family Statistics, person, 16 pounds above the level in 1970. Each American
Washington, DC: U.S. Government Printing Office) consumed an average of 21 pounds less red meat (mostly
beef) than in 1970, 34 pounds more poultry and 3.4 pounds
more fish. (ers.usda.gov/briefing/consumption)
Fat/Meat Consumption
• Between 1965 and 1996 among adults, total fat as a
proportion of daily calorie intake fell steadily from 39.1 to
33.1 percent. Saturated fat fell from 14.4 to 11.0 percent.
However, total calorie intake increased between 1991 and
1996. Over the same period daily total fat consumption rose
from 70.9 grams (g) to 74.8 g. (Prev Med 2001;32:245–54)
• Only 22.7 percent of adults consumed fruits and vegetables
Cholesterol
• The average daily intake of dietary cholesterol in the United
at least 5 times a day in 1996. This was an increase from
19.0 percent in 1990. (BRFSS [1990–96], CDC/NCHS) 11
States is 269.6 mg. For males it’s 323.5 mg and for females • The highest proportion of adults who consumed fruits and
it’s 218.9 mg. (NHANES III [1988–94], CDC/NCHS) vegetables at least 5 times a day were those age 65 and
— For non-Hispanic whites the average is 259.3 milligrams older, whites, college graduates, those actively engaged in
(312.6 mg for males and 209.1 mg for females). leisure-time physical activity, and nonsmokers. (Prev Med
— For non-Hispanic blacks the average is 297.9 milligrams 2001;32:245–54)
(358.8 mg for males and 245.6 mg for females). • The percentage of men who consumed fruits and vegetables
— For Mexican Americans the average is 316.2 milligrams at least 5 times a day increased from 16.5 percent in 1990 to
(365.9 mg for males and 263.8 mg for females). 19.1 percent in 1996. The percentage of women increased
from 21.3 percent in 1990 to 26.2 percent in 1996. (Am J
Public Health 2000;90:777–81)
Fiber • From 1990 to 1996 the percentage of obese adults who
• The recommended daily intake of dietary fiber is 25 grams consumed at least 5 servings of fruits and vegetables a day
or more. Americans consume a daily average of 15.6 grams dropped from 16.8 percent to 15.4 percent. (Prev Med
of dietary fiber (17.8 g for males and 13.6 g for females). 2001;32:245–54)
(NHANES III [1988–94], CDC/NCHS) • Recent studies support the intake of up to 9 servings of
— For non-Hispanic whites the average is 15.8 grams (18.1 fruits and vegetables per day. (NEJM 1997;336:1117–24)
g for males and 13.7 g for females). • In 2003, the percentage of students in grades 9–12 who
— For non-Hispanic blacks the average is 13.4 grams (15.0 reported eating fruits and vegetables 5 or more times per day
g for males and 12.0 g for females). was 23.6 percent for males and 20.3 percent for females.
(YRBS, U.S., 2003, MMWR, Vol. 53, No. SS-2, May 21,
— For Mexican Americans the average is 18.5 grams (21.0
2004, CDC/NCHS)
g for males and 15.9 g for females).
— Black students (24.5 percent) were more likely than
• Analysis of participants in the Cardiovascular Health Study
white students (20.2 percent) to have eaten 5 or more
(CHS) showed that cereal fiber consumption late in life was
servings per day. This racial/ethnic difference was
associated with lower risk of incident CVD, supporting
significantly higher for male students.
recommendations for elderly people to increase
consumption of dietary cereal fiber. (JAMA
2003;289:1659–66) Costs
• Each year over $33 billion in medical costs and $9 billion in
Fruits/Vegetables lost productivity due to heart disease, cancer, stroke and
diabetes are attributed to diet. (CDC)
• In 2000, 81 percent of men and 73 percent of women
reported eating fewer than five servings of fruits and
vegetables a day. More than 60 percent of young people eat
too much fat, and less than 20 percent eat the recommended
five or more servings of fruits and vegetables each day.
(CDC/NCHS, BRFSS, 2000)
12 Quality of Care
The Institute of Medicine defines quality of care as “the

degree to which health services for individuals and
National Veterans Health
populations increase the likelihood of desired health outcomes Administration Data
and are consistent with current professional knowledge.”
The VA collects national quality performance data related to
(Crossing the quality chasm: a new health system for the 21st
cardiovascular disease. Aggregate data from 158 VA hospitals
century. National Academy Press, 2001.) This section of the
from January 1, 2003 to January 1, 2004 are listed below
Update highlights national data on rates of compliance with
(Office of Quality and Performance, Veterans Health
quality measures for several cardiovascular conditions.
Administration). Only patients who were candidates for each
quality indicator were considered (i.e., patients with
National Medicare and contraindications to a given therapy were not considered).
Medicaid Data Acute myocardial infarction Percent of inpatients
In 2003 the Centers for Medicare and Medicaid Services Aspirin within 24 hours of admission 96%
published national data on quality of cardiovascular care indicators Aspirin at discharge 98%
for hospitalized Medicare beneficiaries in 2000–01. Only patients Beta blocker within 24 hours of admission 94%
who were candidates for each quality indicator were considered Beta blocker at discharge 98%
(i.e., patients with contraindications to a given therapy were not ACE inhibitor for patients with LVEF <40% 92%
considered). Smoking cessation advice given 87%
Acute myocardial infarction Percent of inpatients Heart failure Percent of inpatients
Aspirin within 24 hours of admission 85% Documentation of LVEF 99%

Aspirin at discharge 86% ACE inhibitor for patients with LVEF <40% 92%
Beta blocker within 24 hours of admission 69% Complete discharge instructions 76%
Beta blocker at discharge 79% Smoking cessation advice given 76%
ACE inhibitor for patients with LVEF <40% 74% Hypertension Percent of inpatients
Smoking cessation advice given 43%
Median time for thrombolysis 45 minutes Blood pressure at goal (<140/90) 68%
Median time to primary angioplasty 107 minutes Cholesterol Percent of outpatients
Heart failure Percent of inpatients Cholesterol screening in all patients 91%
Evaluation of LVEF 70% Cholesterol measured after acute MI 94%
ACE inhibitor for patients with LVEF <40% 68% LDL cholesterol <130 mg/dL after acute MI 78%
Stroke Percent of inpatients

National Managed Care Data
Warfarin for atrial fibrillation 57%
Antithrombotic therapy for stroke or TIA 84% For 2003, the National Committee for Quality Assurance reported
on 5 quality-of-care performance measures for cardiovascular
Overall, the improvement for these specific quality indicators disease prevention and treatment (The State of Health Care
between 1998–99 and 2000–01 was very modest, 2–7 percent. Quality 2003, Industry Trends and Analysis, NCQA). Note that
NCQA data is reported voluntarily by participating managed care
plans, and that performance data apply to patients receiving
medical care from providers participating in specific managed care
plans in the United States.
Use of beta blockers after a heart attack
• In 2002, 93.5 percent of heart attack survivors enrolled in
commercial managed care plans were receiving a beta
American Heart Association
GWTG-CAD Program 12
blocker at the time of discharge from the hospital, an Get With The GuidelinesSM (GWTG) is a national quality
increase from 62 percent in 1996. If all practices were improvement initiative of the American Heart Association to help
performed at the 90th percentile level, an additional 1,726 hospitals redesign systems of care to improve guidelines adherence
deaths could be avoided each year. in patients admitted with a cardiovascular or stroke event.
The table below summarizes baseline pre-intervention
Cholesterol screening in patients with
performance on the selected quality indicators. These were
coronary heart disease
collected from 30 consecutive patients from 398 hospitals.
• In 2002, 79 percent of patients enrolled in commercial
Performance indicator Percent of inpatients
managed care plans and hospitalized for heart attack, bypass
surgery or angioplasty were screened for LDL cholesterol Aspirin at discharge 91%
between 60 and 365 days after discharge. This proportion Beta blocker at discharge 79%
represented an increase from 59 percent in 1998. ACE inhibitor at discharge 57%
Lipid therapy at discharge 60%
Cholesterol control in patients with Lipid therapy at discharge if LDL >100 mg/dL 72%
coronary heart disease Blood pressure therapy at discharge 70%
Smoking cessation counseling 65%
• In 2002, 61 percent of patients enrolled in commercial
Referral to cardiac rehabilitation 47%
managed care plans and hospitalized for heart attack, bypass
surgery or angioplasty were treated to an LDL cholesterol These data demonstrate the treatment gaps for each of the quality-
goal of less than 130 mg/dL. This proportion represented an of-care indicators. GWTG aims to bridge these gaps in care.
increase from 45 percent in 1999. If all practices were Information on GWTG can be found on this Web site.
performed at the 90th percentile level, 6,500 deaths could be
avoided each year. Note that this treatment goal is less
aggressive than the LDL goal of less than 100 mg/dL National Heart Failure Data
endorsed by the American Heart Association and the The ADHERE (Acute Decompensated HEart Failure National
National Cholesterol Education Program. REgistry) Registry is a national observational registry of patients
hospitalized with acutely decompensated heart failure. Hospitals
Control of high blood pressure
from all regions of the country participate, including community,
• In 2002, 58 percent of adults enrolled in commercial tertiary and academic. The demographics of the 260 hospitals
managed care plans and diagnosed with high blood pressure participating are representative of the nation’s hospitals as a
were controlled to levels less than140/90 mm Hg. This whole. The Joint Commission on Accreditation of Health Care
proportion represented an increase from 40 percent in 1999. Organizations (JCAHO) has created, tested and validated a set of
More than 28,000 lives could be saved and nearly 50,000 heart failure core quality-of-care measures.
strokes could be prevented each year if everyone with Mean performance of the JCAHO quality indicators from 40,046
diagnosed hypertension received care at rates seen at the patients enrolled August 2003 through July 2004 from these 260
90th percentile (68 percent control). U.S. hospitals was as follows:
Control of diabetes JCAHO Performance indicators Percent of inpatients
• In 2002, 33 percent of adults enrolled in commercial Complete set of discharge instructions 47%
managed plans and diagnosed with diabetes were poorly Measure of LV function 87%
controlled (HbA1c >9.5 or not tested). This proportion ACE inhibitor at discharge for patients with
represented a decrease from 38 percent in 1998. (The AHA LVEF < 40 percent, no contraindications 74%
diabetes management goal is to reduce HbA1c to less than 7 Smoking cessation counseling, current smokers 64%
percent.) Additional measures
Advising smokers to quit ACE inhibitor and/or ARB at discharge for 82%
patients with LVEF < 40 percent, no
• In 2002, 68 percent of smokers enrolled in commercial
contraindications
managed care plans were advised to quit, an increase from
Beta blockers at discharge for patients with 73%
59 percent in 1996. Nearly 2,700 lives could be saved each
LVEF < 40 percent, no contraindications
year if all Americans smokers were advised to quit at the
rates seen in plans at the 90th percentile. These patients were hospitalized with a primary diagnosis of heart
failure. The mean age was 72.1 years and 52 percent of them were
female. 58 percent of HF patients had a history of coronary artery
disease. Mechanical ventilation was required in 4.0 percent of
12 patients. In-hospital mortality was 3.8 percent and mean length of
hospital stay was 5.8 days (median 4.3 days).
Further information on the ADHERE registry can be found at
adhereregistry.com.
National Acute Coronary

Syndrome Data
CRUSADE (Can Rapid Stratification of Unstable Angina Patients
Suppress ADverse Outcomes with Early Implementation of the
ACC/AHA Guidelines?) is a national quality improvement
initiative designed to increase adherence to guideline-
recommended care for patients hospitalized with non-ST-segment
elevation myocardial infarction or unstable angina. Over 440
hospitals participate nationwide. Treatment measures from the
CRUSADE registry from a data set of 40,530 patients who were
enrolled in the registry from July 2003 through June 2004 are
as follows:
Acute Medications* ‘Leading’ Centers 'Lagging’ Centers
(within 24 hrs) Overall (Top 25%) (Bottom 25%)
Aspirin 94% 97% 89%
Beta blocker 85% 92% 76%
Heparin, Any 86% 92% 75%
Glycoprotein IIb-IIIa Inhibitor, Any 42% 57% 24%
Discharge Medications**
Aspirin 92% 97% 83%
Clopidogrel 66% 73% 52%
Beta blocker 88% 93% 78%
ACE-I, Overall 60% 68% 48%
ACE-I, Among Recommended# 63% 71% 51%
Lipid-lowering Agent, Overall 74% 82% 60%
Lipid-lowering Agent, Recommended+ 84% 89% 75%
Procedures***
Cardiac Catheterization, Overall 73% 89% 59%
Cardiac Catheterization,
Within 48 hours of Presentation 53% 69% 40%
* Excluding patients with contraindications to these therapies

** Excluding patients with contraindications, transfers out,
and deaths
# Including only patients with history of hypertension, diabetes,
CHF, and LVEF<40%
+ Including only patients with history of hyperlipidemia or
LDL>100mg/dL
*** Excluding patients with contraindications to cardiac
catheterization
Note that not all of the treatment measures reported above are
established quality indicators. Further information on the
CRUSADE registry can be found at its Web site
(www.CRUSADEQI.com).
Medical Procedures and Costs 13
From 1979 to 2002 the total number of cardiovascular operations Trends in Heart Transplants
and procedures increased 470 percent. UNOS: 1968–2003
2,500 2,363 2,199

2,057
Cardiac Catheterization 2,107
Number of Transplants
2,000
• From 1979 to 2002 the number of cardiac catheterizations
increased 389 percent. 1,500
• An estimated 1,463,000 inpatient cardiac catheterizations 1,000 719
were performed in 2002.
• The average total charge for patients hospitalized for 500
23 10 22 57
diagnostic cardiac catheterization increased from $11,232 in
0
1993 to $16,838 in 2000. The total number of patients 1968 70 75 80 85 90 95 00 03
increased from 626,690 to 693,472, while the average length Years
of stay decreased from 4.7 days to 3.6 days. (Agency for
Healthcare Research and Quality, Healthcare Cost and Source: United Network for Organ Sharing (UNOS), scientific registry data.
Utilization Project, HCUPnet, 2000. hcup.ahrq.gov)
Percutaneous Transluminal
Coronary Artery Bypass Coronary Angioplasty (PTCA)
Surgery • An estimated 657,000 PTCA procedures were performed on
In the United States in 2002, the NCHS estimates that 515,000 of 640,000 patients in 2002 in the United States. From 1987 to
these procedures were performed on 306,000 patients. 2002 the number of procedures increased 324 percent.
• In 2002, 66 percent of PTCA procedures were performed on
men; 50 percent were performed on people age 65 and older.
Heart Transplants • The rate of coronary stent insertion increased 147 percent
In 2003, 2,057 heart transplants were performed in the United between 1996 and 2000. Among the elderly, this procedure
States. There are 291 organ transplant centers in the United States, increased 168 percent during the same period. The rate of
173 of which perform heart transplants. stent insertion also more than doubled for the population
45–64 years of age, increasing from 157 to 318 per 100,000.
• In the United States, 74 percent of heart transplant patients (Health Care in America: Trends in Utilization.
are male, 74 percent are white, 21 percent are ages 35–49, CDC/NCHS 2003.)
and 47 percent are ages 50–64.
• In 2002 the 1-year survival rate was 86.8 percent, and the 2-
year rate was 80.9 percent. In 2003, the 1-year survival rate 2002 National HCUP Statistics
was 86.9 percent. Data from the latest Healthcare Cost and Utilization Project
• As of 10/31/04, there were 3,366 heart patients on the (HCUP) provide data for the mean charges and in-hospital death
transplant waiting list. rate for the following (hcup.ahrq.gov):
In-Hospital
Procedure Mean Charges Death Rate
Coronary artery bypass graft $60,853 2.4%
PTCA 28,558 0.9%
Diagnostic cardiac catheterization 17,763 1.0%
Cardiac pacemaker or
cardioverter defibrillator 40,852 1.7%
Endarterectomy, vessel of
head and neck 16,890 0.4%
Heart valves 85,187 5.8%
2002 data from the Healthcare Cost and Utilization Project
13 (HCUP) provide the national bill for the top 100 CCS (Clinical
Classifications Software) diagnoses treated in U.S. hospitals
(hcup.ahrq.gov):
Primary Diagnosis
Coronary atherosclerosis
Rank
1
National
Bill
$38.4 billion
Acute MI 2 27.8 billion
Congestive HF, nonhypertensive 4 21.8 billion
Cardiac dysrhythmias 8 14.3 billion
Acute cerebrovascular disease 9 13.9 billion
Estimated* Inpatient Cardiovascular Operations, Procedures and Patient Data by Sex, Age and Region
United States: 2002 (in Thousands)
Sex Age Region#
Operations/Procedures/Patients Total Male Female <15 15–44 45–64 65+ Northeast Midwest South West
(ICD/9 Code)
Angioplasty (36.0) Procedures 1,204 802 402 — 76 517 608 211 323 416 254
PTCA (36.01, .02, .05) (a) Procedures 657 434 223 — 37 283 331 110 182 223 130
Patients 640 423 217 — 41 278 321 112 175 221 132
Stenting (36.06) Procedures 537 363 174 — 34 228 273 95 138 186 118
Cardiac Revascularization (Bypass)
(36.1–36.3) (b) Procedures 515 373 142 — 19 217 279 104 117 204 90
Patients 306 219 88 — 12 128 166 60 68 125 54
Diagnostic Cardiac Catheterizations
(37.2) (a) Procedures 1,463 884 579 10 123 597 732 281 342 585 255
Endarterectomy (38.12) Procedures 134 79 56 — — 33 101 33 29 55 17
Implantable Defibrillators (37.94–.99) Procedures 63 45 11 — — 21 36 13 14 20 9
Open-Heart Surgery (c) Procedures 709 476 233 30 41 261 368 160 150 258 127
Pacemakers (37.8) (d) Procedures 199 101 99 — — 21 172 50 36 78 36
Valves (35.1, .2, .99) (e) Procedures 93 49 44 — 9 19 56 25 15 25 18
Total Vascular and Cardiac Surgery
and Procedures (35–39)** 6,813 3,967 2,845 210 681 2,384 3,538 1,370 1,463 2,601 1,378

* Breakdowns are not available for some procedures, so entries for some categories don’t add to totals. These data include codes where the estimated number of procedures is
fewer than 5,000. Categories of such small numbers are considered unreliable by CDC/NCHS and in some cases may have been omitted.
** Totals include procedures not shown here.
# Regions: Northeast — Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Midwest — Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
South — Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee,
Texas, Virginia, West Virginia
West — Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming
(a) — Does not include procedures in the outpatient or other non-hospitalized setting; thus, excludes some cardiac catheterizations and PTCAs.
(b) — Because one or more procedure codes are required to describe the specific bypass procedure performed, it’s impossible from this (mixed) data to determine the average number of grafts
per patient.
(c) — Includes valves, bypass and 101,000 “other” open-heart procedures. (Codes 35 [less 35.1–35.2, 35.4, 35.96, 35.99]; 36 [less 36.0–36.1]; 37.1, 37.3–37.5.)
(d) — There are additional insertions, revisions and replacements of pacemaker leads, including those associated with temporary (external) pacemakers.
(e) — Open heart valvuloplasty without replacement; replacement of heart valve; other operations on heart valves.
Source: Health Resources Utilization Branch, CDC/NCHS. Estimates are based on a sample of inpatient records from short-stay hospitals in the United
States (National Hospital Discharge Survey).
Trends in Cardiovascular Operations and Procedures

1,600
1,400
Procedures in Thousands
1,200
1,000
800
600
400
200
0
79 80 85 90 95 00 01 02
Years
Catheterizations Open-Heart Bypass
PTCA Endarterectomy Pacemakers
Source: CDC/NCHS.
Economic Cost of
Cardiovascular Diseases 14
The cost of cardiovascular diseases and stroke in the United States Estimated Direct and Indirect Costs (in Billions of
in 2005 is estimated at $393.5 billion. This figure includes health Dollars) of Cardiovascular Diseases and Stroke
expenditures (direct costs, which include the cost of physicians United States: 2005
and other professionals, hospital and nursing home services, the
393.5
cost of medications, home health care and other medical durables) 400
and lost productivity resulting from morbidity and mortality 350
Billions of Dollars
(indirect costs). By comparison, in 2004 the estimated cost of all 300 254.8
cancers was $190 billion ($69 billion in direct costs, $17 billion in 250
morbidity indirect costs and $104 billion in mortality indirect
200
costs). In 1999 the estimated cost of HIV infections was $28.9 142.1
billion ($13.4 billion direct and $15.5 billion indirect). 150
100 56.8 59.7
50 27.9
0
Heart Coronary Stroke Hypertensive Congestive Total CVD*
Disease Heart Disease Heart
Disease Failure
Estimated Direct and Indirect Costs (in Billions of Dollars) of Cardiovascular Diseases and Stroke
United States: 2005
Coronary Congestive Total
Heart Heart Hypertensive Heart Cardiovascular
Diseases** Disease Stroke Disease Failure Disease*
Direct Costs
Hospital $77.7 $39.9 $14.8 $6.0 $14.7 $109.8
Nursing Home 19.1 10.0 13.2 3.9 3.6 39.3
Physicians/Other Professionals 18.5 10.4 2.9 10.4 1.9 36.0
Drugs/Other
Medical Durables 19.4 9.0 1.2 22.3 2.9 45.9
Home Health Care 4.8 1.4 2.9 1.6 2.2 10.9
Total Expenditures* $139.5 $70.7 $35.0 $44.2# $25.3 $241.9
Indirect Costs
Lost Productivity/Morbidity 21.4 9.4 6.3 7.5 — 34.8
Lost Productivity/Mortality ## 93.9 62.0 15.5 8.0 2.6 116.8
Grand Totals* $254.8 $142.1 $56.8 $59.7 $27.9 $393.5

* Totals do not add up due to rounding and overlap.
** This category includes coronary heart disease, congestive heart failure, part of hypertensive disease, cardiac dysrhythmias, rheumatic heart disease,
cardiomyopathy, pulmonary heart disease, and other or ill-defined “heart” diseases.
# Tom Hodgson and Liming Cai (Medical Care 2001) estimated that healthcare expenditures attributed to hypertension that could be allocated to cardiovascular
complications and other diagnoses totaled $108 billion in 1997.
## Lost future earnings of persons who will die in 2005, discounted at 3 percent.
Sources: Hodgson TA, Cohen AJ. Medical care expenditures for selected circulatory diseases: opportunities for reducing national health expenditures.
Medical Care. 1999;37:994–1012.
National Health Expenditures Amounts, and Average Annual Percent Change, by Type of Expenditure: Selected Calendar Years
1990–2013 (cms.hhs.gov).
Rice DP, Hodgson TA, Kopstein AN. The economic costs of illness: a replication and update. Health Care Financ Rev. 1985;7:61–80.
Historic Income Tables — People (census.gov).
Deaths for 358 Selected Causes by 5-Year Age Groups, Race, and Sex, United States, 2001 (cdc.nchs/default/htm).
Rice, Max, Michel, and Sung. Present Value of Lifetime Earnings, U.S. 2001. Unpublished tables, Institute for Health and Aging, University of
California, San Francisco, 2004.
All estimates prepared by Thomas Thom, NHLBI.
At-a-Glance Summary Tables
15 Men and Cardiovascular Diseases
Diseases and Total Total White Black Mexican-American

Risk Factors Population Males Males Males Males
Total CVD
Prevalence 2002 70.1 M (34.2%) 32.5 M (34.4%) 34.3% 41.1% 29.2%
Mortality 2002 (preliminary) 927.4K 433.8 K 375.4 K 49.0 K —
Prevalence 2002 CHD 13.0 M (6.9%) 7.1 M (8.4%) 8.9% 7.4% 5.6%
Prevalence 2002 MI 7.1 M (3.5%) 4.1 M (5.0%) 5.1% 4.5% 3.4%
Prevalence 2002 AP 6.4 M (3.8%) 3.1 M (4.2%) 4.5% 3.1% 2.4%
New and recurrent CHD* 1.2 M 715.0 K 650.0 K 65.0 K —
New and recurrent MI 865.0 K 520.0 K — — —
Incidence AP (stable angina) 400.0 K — — — —
Mortality 2002 CHD 494.4 K 252.8 K 223.3 K 24.3 K —
Mortality 2002 MI 179.5 K 93.8 K 83.3 K 8.7 K —
Stroke
Prevalence 2002 5.4 M (2.6%) 2.4 M (2.5%) 2.3% 4.0% 2.6%
New and recurrent attacks 700.0 K 327.0 K 277.0 K 50.0 K —
Mortality 2002 162.7 K 62.6 K 53.0 K 7.8 K —
High Blood Pressure
Prevalence 2002 65.0 M (32.3%) 29.4M (31.5%) 30.6% 41.8% 27.8%
Mortality 2002 49.7 K 20.5 K 14.7 K 5.3 K —
Congestive Heart Failure
Prevalence 2002 4.9 M (2.3%) 2.4 M (2.6%) 2.5% 3.1% 2.7%
Mortality 2001 52.8 K 19.8 K 17.8 K 1.8 K —
Tobacco
Prevalence 2002 48.5 M (22.5%) 26.3 M (25.2%) 25.2% 27.0% —
Blood Cholesterol
Prevalence 2002:
Total cholesterol 200 mg/dL+ 106.9 M (50.7%) 50.4 M (50.4%) 51.0% 37.3% 54.3%
LDL cholesterol 130 mg/dL+ 95.0 M (45.8%) 48.6 M (48.5%) 49.6% 46.3% 43.6%
HDL cholesterol <40 mg/dL 54.7 M (26.4%) 39.0 M (39.0%) 40.5% 24.3% 40.1%
Physical Inactivity
Prevalence 1999–2001 38.6% 35.8% 34.4% 45.1% —
Prevalence 2002:
Overweight BMI 25.0 or higher 134.8 M (65.1%) 68.6 M (68.8%) 69.4% 62.9% 73.1%
Obesity BMI 30.0 or higher 63.1 M (30.4%) 27.5 M (27.6%) 28.2% 27.9% 27.3%
Diabetes Mellitus
Prevalence 2002:
Physician-diagnosed diabetes 13.9 M (6.7%) 6.8 M (7.2%) 6.2% 10.3% 10.4%
Undiagnosed diabetes 5.9 M (2.8%) 2.9 M (2.9%) 3.0% 1.3% 3.5%
Pre-diabetes 14.5 M (7.0%) 8.5 M (8.9%) 8.6% 8.3% 8.7%
Incidence 1.3M — — — —
Mortality 73.2 K 34.3 K 28.1 K 5.2 K —
Note: AP = angina pectoris (chest pain); BMI = body mass index; CHD = coronary heart disease; includes heart attack, angina pectoris (chest pain) or both;
CVD = cardiovascular disease; K = thousands; M = millions; MI = myocardial infarction (heart attack); mg/dL = milligrams per deciliter; (—) = data not available.
* New and recurrent heart attacks and fatal CHD.
Sources: See expanded version of the 2005 statistical update, at americanheart.org/statistics. For data on men in other ethnic groups, see other chapters and Statistical Fact
At-a-Glance Summary Tables
Women and Cardiovascular Diseases 15
Diseases and Total Total White Black Mexican-American
Risk Factors Population Females Females Females Females
Total CVD
Prevalence 2002 70.1 M (34.2%) 37.6 M (33.9%) 32.4% 44.7% 29.3%
Mortality 2002 (preliminary) 927.4 K 493.6 K 428.5 K 56.7 K —
Prevalence 2002 CHD 13.0 M (6.9%) 5.9 M (5.6%) 5.4% 7.5% 4.3%
Prevalence 2002 MI 7.1 M (3.5%) 3.0 M (2.3%) 2.4% 2.7% 1.6%
Prevalence 2002 AP 4.8 M (3.8%) 3.3 M (3.6%) 3.5% 4.7% 2.2%
New and recurrent CHD* 1.2 M 485.0 K 425.0 K 60.0 K —
New and recurrent MI 865.0 K 345.0 K — — —
Incidence AP (stable angina) 400.0 K — — — —
Mortality 2002 CHD 494.4 K 241.6 K 211.9 K 25.9 K —
Mortality 2002 MI 179.5 K 85.7 K 74.6 K 9.6 K —
Stroke
Prevalence 2002 5.4 M (2.6%) 3.0 M (2.6%) 2.6% 3.9% 1.8%
New and recurrent attacks 700.0 K 373.0 K 312.0 K 61.0 K —
Mortality 2002 162.7 K 100.1 K 86.8 K 11.0 K —
High Blood Pressure
Prevalence 2002 65.0 M (32.3%) 35.6M (32.8%) 31.0% 45.4% 28.7%
Mortality 2002 49.7 K 29.2 K 22.3 K 6.3 K —
Prevalence 2002 4.9 M (2.3%) 2.5M (2.1%) 1.9% 3.5% 1.6%
Mortality 2001 52.8 K 33.0 K 29.9 K 2.8 K —
Tobacco
Prevalence 2002 48.5 M (22.5%) 21.2 M (20.0%) 20.7% 18.5% —
Blood Cholesterol
Prevalence 2002:
LDL cholesterol 130 mg/dL+ 95.0 M (45.8%) 46.4 M (43.3%) 43.7% 41.6% 41.6%
HDL cholesterol <40 mg/dL 54.7 M (26.4%) 15.9 M (14.9%) 14.5% 13.0% 18.4%
Physical Inactivity
Prevalence 1999–2001 38.6% 41.0% 38.3% 55.1% —
Prevalence 2002:
Overweight BMI 25.0 or higher 134.8 M (65.1%) 66.2 M (61.6%) 57.2% 77.2% 71.7%
Obesity BMI 30.0 or higher 63.1 M (30.4%) 35.6 M (33.2%) 30.7% 49.0% 38.4%
Diabetes Mellitus
Prevalence 2002:
Physician-diagnosed diabetes 13.9 M (6.7%) 7.0 M (6.3%) 4.7% 12.6% 11.3%
Undiagnosed diabetes 5.9 M (2.8%) 3.0 M (2.7%) 2.7% 6.1% 1.8%
Pre-diabetes 14.5 M (7.0%) 6.0 M (5.4%) 4.6% 5.9% 7.2%
Incidence 1.3 M — — — —
Mortality 73.2 K 38.9 K 30.3 K 7.5 K —
Sources: See expanded version of the 2005 statistical update, at americanheart.org/statistics. For data on women in other ethnic groups, see other chapters and Statistical Fact Sheets.
At-a-Glance
Women, Summary
Children and Tables
15 Cardiovascular Diseases
Ethnic Groups and Cardiovascular Diseases
Diseases and Total Whites Blacks/African Mexican Hispanics/

Risk Factors Population Americans Americans Latinos
Males Females Males Females Males Females Males Females
Total CVD
Prevalence 2002 70.1 M (34.2%) 34.3% 32.4% 41.1% 44.7% 29.2% 29.3% — —
Mortality 2002 (preliminary) 927.4 K 375.4 K 428.5 K 49.0 K 56.7 K — — — —
Prevalence 2002 CHD 13.0 M (6.9%) 8.9% 5.4% 7.4% 7.5% 5.6% 4.3% 4.8%
Prevalence 2002 MI 7.1 M (3.5%) 5.1% 2.4% 4.5% 2.7% 3.4% 1.6% — —
Prevalence 2002 AP 6.4 M (3.8%) 4.5% 3.5% 3.1% 4.7% 2.4% 2.2% — —
New and recurrent CHD* 1.2 M 650.0 K 425.0 K 65.0 K 60.0 K — — — —
Mortality 2002 CHD 494.4 K 223.3 K 211.9 K 24.3 K 25.9 K — — — —
Mortality 2002 MI 179.5 K 83.3 K 74.6 K 8.7 K 9.6 K — — — —
Stroke
Prevalence 2002 5.4 M (2.6%) 2.3% 2.6% 4.0% 3.9% 2.6% 1.8% 2.4%
New and recurrent attacks 700.0 K 277.0 K 312.0 K 50.0 K 61.0 K — — — —
Mortality 2002 162.7 K 53.0 K 86.8 K 7.8 K 11.0 K — — — —
High Blood Pressure
Prevalence 2002 65.0 M (32.3%) 30.6% 31.0% 41.8% 45.4% 27.8% 28.7% 18.2%
Mortality 2002 49.7 K 14.7 K 22.3 K 5.3 K 6.3 K — — — —
Prevalence 2002 4.9 M (2.3%) 2.5% 1.9% 3.1% 3.5% 2.7% 1.6% — —
Mortality 2001 52.8 K 17.8 K 29.9 K 1.8 K 2.8 K — — — —
Tobacco
Prevalence 2002 48.5 M (22.5%) 25.2% 20.7% 27.0% 18.5% — — 23.2%** 12.5%**
Blood Cholesterol
Prevalence 2002:
Total cholesterol 200 mg/dL+ 106.9 M (50.7%) 51.0% 53.6% 37.3% 46.4% 54.3% 44.7% — —
Total cholesterol 240 mg/dL+ 37.7 M (18.3%) 17.8% 19.9% 10.6% 17.7% 17.8% 13.9% 25.6%
LDL cholesterol 130 mg/dL+ 95.0 K (45.8%) 49.6% 43.7% 46.3% 41.6% 43.6% 41.6% — —
HDL cholesterol <40 mg/dL 54.7 K (26.4%) 40.5% 14.5% 24.3% 13.0% 40.1% 18.4% — —
Physical Inactivity
Prevalence 1999–2001 38.6% 34.4% 38.3% 45.1% 55.1% — — 52.6% 57.2%
Prevalence 2002:
Overweight BMI 25.0 or higher 134.8 M (65.1%) 69.4% 57.2% 62.9% 77.2% 73.1% 71.7% 65.2%
Obesity BMI 30.0 or higher 63.1 M (30.4%) 28.2% 30.7% 27.9% 49.0% 27.3% 38.4% 25.4%
Diabetes Mellitus
Prevalence 2002:
Physician-diagnosed diabetes 13.9 M (6.7%) 6.2% 4.7% 10.3% 12.6% 10.4% 11.3% 9.4%
Undiagnosed diabetes 5.9 M (2.8%) 3.0% 2.7% 1.3% 6.1% 3.5% 1.8% — —
Pre-diabetes 14.5 M (7.0%) 8.6% 4.6% 8.3% 5.9% 8.7% 7.2% — —
Incidence 1.3 M — — — — — — — —
Mortality 73.2 K 28.1 K 30.3 K 5.2 K 7.5 K — — — —
** Data are for 1999–2001.
Sources: See expanded version of the 2005 statistical update, at americanheart.org/statistics. For data on other ethnic groups, see other chapters and Statistical Fact Sheets.
Cardiovascular
At-a-Glance Diseases
Summary Tables
Children, Youth and Cardiovascular Diseases 15
Diseases and Total Total Total Non-Hispanic Non-Hispanic Mexican

Risk Factors Population Males Females Whites Blacks Americans
Males Females Males Females Males Females
Congenital Defects
Mortality 2001 (all ages) 4.1 K 2.2 K 1.9 K 1.8 K 1.5 K 0.4 K 0.3 K — —
Mortality 2001 (< age 15) 2.1 K 1.2 K 1.0 K — — — — — —
Tobacco
Prevalence ages 12–17:
Current cigarette use 1999–2001 — 13.3% 14.2% 14.9% 17.2% 8.2% 5.9% 11.4%* 10.6%*
High school students
(Grades 9-12):
Current cigarette smoking 2003 — 21.8% 21.9% 23.3% 26.6% 19.3% 10.8% 19.1%* 17.7%*
Current cigar smoking 2003 — 19.9% 9.4% 21.3% 8.6% 19.5% 10.3% 14.9%* 12.2%*
Smokeless tobacco use 2003 — 11.0% 2.2% 13.2% 1.6% 4.1% 2.0% 6.1%* 3.3%*
Blood Cholesterol
Ages 4–19:
Mean total cholesterol mg/dL 165 163 167 162 166 168 171 163 165
Ages 4–19:
Mean HDL cholesterol mg/dL — — — 48 50 55 56 51 52
Ages 12–19:
Mean LDL cholesterol mg/dL — — — 91 100 99 102 93 92
Physical Inactivity
Prevalence 2003 grades 9–12:
Vigorous activity last 7 days — — — 71.9% 58.1% 65.0% 44.9% 66.7%* 51.8%*
Moderate activity last 7 days — — — 28.9% 23.3% 25.8% 17.5% 23.3%* 20.6%*
Overweight
Prevalence 2002:
Preschool children ages 2–5 >10% — — 8.6% 8.8% 13.1%
Children ages 6–11 3.9 M 2.1 M 1.8 M 14.0% 13.1% 17.0% 22.8% 26.5% 17.1%
(15.8%) (16.9%) (14.7%)
Adolescents ages 12–19 5.3 M 2.8 M 2.5 M 14.6% 12.7% 18.7% 23.6% 24.7% 19.9%
(16.1%) (16.7%) (15.4%)
Students grades 9–12 — — — 16.2% 7.8% 19.5% 15.6% 21.7%* 11.8%*
Note: K = thousands; M = millions; mg/dL = milligrams per deciliter; overweight in children is body mass index (BMI) 95th percentile of the CDC 2000 growth
chart; (—) = data not available.
* Hispanic.
Sources: See expanded version of the 2005 statistical update, at americanheart.org/statistics. For more data on congenital defects, see pages 24-25, and our Statistical Fact
Sheet, Congenital Cardiovascular Defects.
16 Glossary 16
Age-Adjusted Rates — Used mainly to compare the rates of two or more Coronary Heart Disease (ICD/10 codes I20–I25) — This category
communities, population groups or the nation as a whole, over time. We includes acute myocardial infarction (I21–I22); other acute ischemic
use a standard population (2000), so that these rates aren’t affected by (coronary) heart disease (I24); angina pectoris (I20); atherosclerotic
changes or differences in the age composition of the population. cardiovascular disease (I25.0); and all other forms of chronic ischemic
heart disease (I25.1–I25.9).
Body Mass Index (BMI) — A mathematical formula to assess body
weight relative to height. The measure correlates highly with body fat. Death Rate — The relative frequency with which death occurs within
Calculated as weight in kilograms divided by the square of the height in some specified interval of time in a population. National death rates are
meters (kg/m2). computed per 100,000 population. Dividing the mortality by the
population gives a crude death rate. It’s restricted because it doesn’t reflect
Centers for Disease Control and Prevention/National Center for
a population’s composition with respect to such characteristics as age, sex,
Health Statistics (CDC/NCHS) — A division of the U.S. Department of
race or ethnicity. Thus rates calculated within specific subgroups, such as
Health and Human Services (USDHHS). The CDC conducts the:
age-specific or sex-specific rates, are often more meaningful and
• Behavioral Risk Factor Surveillance System (BRFSS), an informative. They allow you to look at well-defined subgroups of the total
ongoing study. population.
The NCHS conducted the: Diseases of the Circulatory System — ICD codes (I00–I99); included as
part of what the American Heart Association calls “Cardiovascular
• National Health Examination Survey (NHES).
Disease.” You can obtain mortality data for states from cdc.gov/nchs, by
• National Health and Nutrition Examination Survey I (NHANES I, direct communication with the CDC/NCHS, or from our National Center
1971–74). Biostatistics Program Coordinator on request. (See “Total Cardiovascular
Disease” in this Glossary.)
• National Health and Nutrition Examination Survey II
(NHANES II, 1976–80). Diseases of the Heart — Classification the NCHS uses in compiling the
leading causes of death. Includes acute rheumatic fever/chronic rheumatic
• National Health and Nutrition Examination Survey III (NHANES III,
heart diseases (I00–I09); hypertensive heart disease (I11) and hypertensive
1988–94). Prevalence estimates for coronary heart disease, stroke and
heart and renal disease (I13); coronary heart disease (I20–I25); pulmonary
congestive heart failure are based on the self-reported questionnaire
heart disease and diseases of pulmonary circulation (I26–I28); congestive
portion of this study. Exam-based estimates are being developed.
heart failure (I50.0); and other forms of heart disease (I29–I49, I50.1–I51).
• National Health and Nutrition Examination Survey (NHANES, “Diseases of the Heart” is not equivalent to “Total Cardiovascular
1999–2000). Disease,” which we prefer to use to describe the leading causes of death.
“Diseases of the Heart” represents about three-fourths of “Total
The NCHS also conducts these ongoing studies (among others):
Cardiovascular Disease” mortality.
• National Health Interview Survey (NHIS)
Health Care Financing Administration (HCFA) — See Centers for
• National Hospital Ambulatory Medical Care Survey Medicare and Medicaid Services (CMS).
• National Home and Hospice Care Survey Hispanic Origin — In U.S. government statistics, “Hispanic” includes
persons who trace their ancestry to Mexico, Puerto Rico, Cuba, Spain, the
• National Hospital Discharge Survey
Spanish-speaking countries of Central or South America, the Dominican
Centers for Medicare and Medicaid Services (CMS), formerly Health Republic or other Spanish cultures, regardless of race. It doesn’t include
Care Financing Administration (HCFA) — The federal agency that people from Brazil, Guyana, Suriname, Trinidad, Belize and Portugal
administers the Medicare, Medicaid and Child Health Insurance Programs, because Spanish is not the first language in those countries. Much of our
which provide health insurance for more than 74 million Americans. data are for Mexican Americans or Mexicans, as reported by government
agencies or specific studies. In many cases, data for all Hispanics are more
Comparability Ratio — Provided by the NCHS to allow time-trend
difficult to obtain.
analysis from one ICD revision to another. It compensates for the
“shifting” of deaths from one causal code number to another. Its Hospital Discharges — The number of inpatients discharged from short-
application to mortality based on one ICD revision means that mortality is stay hospitals where some type of disease was the first listed diagnosis.
“comparability-modified” to be more comparable to mortality coded to the Discharges include people both living and dead.
other ICD revision.
ICD and ICDA Codes — A classification system in standard use in the National Institute of Neurological Disorders and Stroke (NINDS) —
16 United States. The “International Classification of Diseases, Adapted”

(ICDA) is based on the “International Classification of Diseases” (ICD)
published by the World Health Organization. This system is reviewed and
An institute in the National Institutes of Health in the U.S. Department of
Health and Human Services. The NINDS sponsors and conducts research
studies such as these:
16
revised about every 10 to 20 years to ensure its continued flexibility and
• Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS)
feasibility. We are in the tenth revision (ICD/10) with the release of 1999
final mortality data. • Rochester (Minnesota) Stroke Epidemiology Project
The ICD revisions can cause considerable change in the number of deaths • Northern Manhattan Stroke Study (NOMASS)
reported for a given disease. The NCHS provides “comparability ratios” to
• Brain Attack Surveillance in Corpus Christi (BASIC) Project
compensate for the “shifting” of deaths from one ICD code to another. In
this booklet we use the reported mortality when we want to show one Prevalence — An estimate of the total number of cases of a disease
year’s data. When we want to compare the number or rate of deaths with existing in a population at a specific point in time. Prevalence is sometimes
that of an earlier year, then we use the “comparability-modified” number expressed as a percentage of population. Rates for specific diseases are
or rate. calculated from periodic health examination surveys that government
agencies conduct. Annual changes in prevalence as reported in this booklet
Incidence — An estimate of the number of new cases of a disease that
only reflect changes in the population; rates do not change until there’s a
develop in a population in a one-year period. For some statistics, new and
new survey.
recurrent attacks or cases are combined. The incidence of a specific disease
is estimated by multiplying the incidence rates reported in community- or NOTE: In the data tables which precede the different disease and risk
hospital-based studies by the U.S. population. The rates change only factor categories, if the percentages shown are age-adjusted, they will
when new data are available; they are not computed annually. not add to the total.
Major Cardiovascular Diseases — Disease classification commonly Race and Hispanic Origin — Race and Hispanic origin are reported
reported by the NCHS; represents ICD codes I00–I78. We don’t use separately on death certificates. In this publication, unless otherwise
“Major CVD” for any calculations. See “Total Cardiovascular Disease” in specified, deaths of Hispanic origin are included in the totals for whites,
this Glossary. blacks, American Indians or Alaska Natives and Asian or Pacific Islanders,
according to the race listed on the decedent’s death certificate. Data for
Morbidity — Incidence and prevalence rates are both measures of
Hispanic persons include all persons of Hispanic origin of any race. See
morbidity, that is, measures of various effects of disease on a population.
“Hispanic Origin” in this Glossary.
Mortality — The total number of deaths from a given disease in a
Stroke (ICD/10 codes I60–I69) — This category includes subarachnoid
population during a specific interval of time, usually a year. These data are
hemorrhage (I60); intracerebral hemorrhage (I61); other nontraumatic
compiled from death certificates and sent by state health agencies to the
intracranial hemorrhage (I62); cerebral infarction (I63); stroke, not
NCHS. The process of verifying and tabulating the data takes about two
specified as hemorrhage or infarction (I64); occlusion and stenosis of
years. For example, 2002 mortality statistics, the latest available, didn’t
precerebral arteries, not resulting in cerebral infarction (I65); occlusion and
become available until late 2004. Mortality is “hard” data, so it’s possible
stenosis of cerebral arteries, not resulting in cerebral infarction (I66); other
to do time-trend analysis and compute percent changes over time.
cerebrovascular diseases (I67); cerebrovascular disorders in diseases
National Heart, Lung, and Blood Institute (NHLBI) — An institute in classified elsewhere (I68) and sequalae of cerebrovascular disease (I69).
the National Institutes of Health in the U.S. Department of Health and
Total Cardiovascular Disease (ICD/10 codes I00–I99, Q20–Q28) —
Human Services. The NHLBI conducts such studies as the:
This category includes rheumatic fever/rheumatic heart disease (I00–I09);
• Framingham Heart Study (FHS) (1948 to date). hypertensive diseases (I10–I15); ischemic (coronary) heart disease
(I20–I25); pulmonary heart disease and diseases of pulmonary circulation
• Honolulu Heart Program (HHP) (1965–97).
(I26–I28); other forms of heart disease (I30–I52); cerebrovascular disease
• Cardiovascular Health Study (CHS) (1988 to date). (stroke) (I60–I69); atherosclerosis (I70); other diseases of arteries,
arterioles and capillaries (I71–I79); diseases of veins, lymphatics and
• Atherosclerosis Risk in Communities (ARIC) study (1985 to date).
lymph nodes, not classified elsewhere (I80–I89); and other and unspecified
• Strong Heart Study (SHS) (1989–92; 1991–98). disorders of the circulatory system (I95–I99). When data are available, we
include congenital cardiovascular defects (Q20–Q28).
The NHLBI also publishes the reports of the Joint National Committee on
Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Total Mention Mortality — The total number of times in a given year
JNC 7 is the most recent. that a disease was listed on death certificates as an underlying or
contributing cause of death.
16 Abbreviation Guide
ACE . . . . . . . . . . . . angiotensin-converting enzyme LV. . . . . . . . . . . . . . left ventricular

ACS . . . . . . . . . . . . acute coronary syndrome LVEF . . . . . . . . . . . left ventricular ejection fraction
ADHERE . . . . . . . . Acute Decompensated HEart Failure MACDP . . . . . . . . . Metropolitan Atlanta Congenital Defects Program
National REgistry MetS. . . . . . . . . . . . metabolic syndrome
AED . . . . . . . . . . . . automated external defibrillator mg/dL. . . . . . . . . . . milligrams per deciliter
AF . . . . . . . . . . . . . atrial fibrillation MI. . . . . . . . . . . . . . myocardial infarction
AHA. . . . . . . . . . . . American Heart Association mm Hg . . . . . . . . . . millimeters of mercury
AIDS . . . . . . . . . . . acquired immune deficiency syndrome MMWR . . . . . . . . . Morbidity and Mortality Weekly Report
AJC . . . . . . . . . . . . American Journal of Cardiology NCEP . . . . . . . . . . . National Cholesterol Education Program
AP . . . . . . . . . . . . . angina pectoris NCHS. . . . . . . . . . . National Center for Health Statistics
ARIC . . . . . . . . . . . Atherosclerosis Risk in Communities NCQA . . . . . . . . . . National Committee for Quality Assurance
ATP . . . . . . . . . . . . Adult Treatment Panel NEJM . . . . . . . . . . . New England Journal of Medicine
BMI . . . . . . . . . . . . body mass index NHANES . . . . . . . . National Health and Nutrition Examination Survey
BP. . . . . . . . . . . . . . blood pressure NHES . . . . . . . . . . . National Health Examination Survey
BRFSS . . . . . . . . . . Behavioral Risk Factor Surveillance System NHIS . . . . . . . . . . . National Health Interview Survey
BWIS . . . . . . . . . . . Baltimore-Washington Infant Study NHLBI . . . . . . . . . . National Heart, Lung, and Blood Institute
CAD . . . . . . . . . . . . coronary artery disease NIHSS . . . . . . . . . . National Institutes of Health Stroke Scale
CDC . . . . . . . . . . . . Centers for Disease Control and Prevention NINDS . . . . . . . . . . National Institute of Neurological Disorders
CHD . . . . . . . . . . . . coronary heart disease and Stroke
CHF . . . . . . . . . . . . congestive heart failure NOMASS. . . . . . . . Northern Manhattan Stroke Study
CHS . . . . . . . . . . . . Cardiovascular Health Study NRMI . . . . . . . . . . . National Registry of Myocardial Infarction
CMS . . . . . . . . . . . . Centers for Medicare and Medicaid Services NVSS . . . . . . . . . . . National Vital Statistics System
CPI . . . . . . . . . . . . . Consumer Price Index OR . . . . . . . . . . . . . odds ratio
CPR . . . . . . . . . . . . cardiopulmonary resuscitation PA. . . . . . . . . . . . . . physical activity
CVD . . . . . . . . . . . . cardiovascular disease PAD . . . . . . . . . . . . peripheral arterial disease
DVT . . . . . . . . . . . . deep vein thrombosis PTCA . . . . . . . . . . . percutaneous transluminal coronary angioplasty
ED . . . . . . . . . . . . . emergency department PE. . . . . . . . . . . . . . pulmonary embolism
EMS . . . . . . . . . . . . emergency medical services PTE . . . . . . . . . . . . pulmonary thromboembolism
ER . . . . . . . . . . . . . emergency room PVD . . . . . . . . . . . . peripheral vascular disease
ESRD . . . . . . . . . . . end-stage renal disease RF. . . . . . . . . . . . . . rheumatic fever
FHS . . . . . . . . . . . . Framingham Heart Study RHD . . . . . . . . . . . . rheumatic heart disease
GCNKSS . . . . . . . . Greater Cincinnati/Northern Kentucky Stroke Study RR . . . . . . . . . . . . . relative risk
GWTG . . . . . . . . . . Get With The GuidelinesSM SAH . . . . . . . . . . . . subarachnoid hemorrhage
HBP . . . . . . . . . . . . high blood pressure SCD . . . . . . . . . . . . sudden cardiac death
HCFA . . . . . . . . . . . Health Care Financing Administration SES. . . . . . . . . . . . . socioeconomic status
HCUP. . . . . . . . . . . Healthcare Cost and Utilization Project SHS . . . . . . . . . . . . Strong Heart Study
HDL . . . . . . . . . . . . high-density lipoprotein STEMI . . . . . . . . . . ST elevation myocardial infarction
HHP . . . . . . . . . . . . Honolulu Heart Program TIA. . . . . . . . . . . . . transient ischemic attack
HIV . . . . . . . . . . . . human immunodeficiency virus UA . . . . . . . . . . . . . unstable angina
ICD. . . . . . . . . . . . . International Classification of Diseases UNOS. . . . . . . . . . . United Network for Organ Sharing
ICDA . . . . . . . . . . . International Classification of Diseases, Adapted USDA. . . . . . . . . . . United States Department of Agriculture
ICH. . . . . . . . . . . . . intracerebral hemorrhage USDHHS . . . . . . . . United States Department of Health and
JACC . . . . . . . . . . . Journal of the American College of Cardiology Human Services
JAMA. . . . . . . . . . . Journal of the American Medical Association VF . . . . . . . . . . . . . ventricular fibrillation
JCAHO. . . . . . . . . . Joint Commission on Accreditation of Health Care VSD . . . . . . . . . . . . ventricular septal defect
Organizations VTE . . . . . . . . . . . . venous thromboembolism
JNC . . . . . . . . . . . . Joint National Committee on Prevention, Detection, WHO . . . . . . . . . . . World Health Organization
Evaluation and Treatment of High Blood Pressure YLL . . . . . . . . . . . . years of life lost
kcal. . . . . . . . . . . . . kilocalories YMCLS . . . . . . . . . Youth Media Campaign Longitudinal Study
LDL . . . . . . . . . . . . low-density lipoprotein YRBS . . . . . . . . . . . Youth Risk Behavior Surveillance
For heart- or risk-related
information, call 1-800-AHA-USA1
(1-800-242-8721) or contact your
nearest office. You can also visit us
online at americanheart.org.
For stroke information, call our

American Stroke Association at
1-888-4-STROKE (1-888-478-7653),
or visit StrokeAssociation.org.
For information on life after stroke,
call and ask for the Stroke Family
Support Network.
Your contributions will support

research and educational programs
that help reduce disability and death
from America’s No. 1 and No. 3 killers.
National Center
7272 Greenville Avenue
Dallas, Texas 75231-4596
©2005, American Heart Association. 1/05 KC-0078

American Heart Association Stats 2005 Update

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American Heart Association Stats 2005 Update

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H artt Disease

Hea isea e aand

Our guide to current statistics and

Check Our Web Sites

About These Statistics

Overweight and Obesity Stroke

• Congestive heart failure — 4,900,000.

700 0.4% Congenital

Note: See Glossary on page 58 for an explanation of “Diseases of 18% Stroke

Hospital Discharges for Cardiovascular Diseases Prevalence of Cardiovascular Diseases in Americans

Percent of Total Deaths

A Diseases of the Heart, D Diabetes Mellitus

Per 100,000 Population

Note: “Asian or Pacific Islander” is a heterogeneous category that

A Diseases of the Heart, D Diabetes Mellitus

Alabama 49 379.4 –14.2 22 154.8 –22.2 44 66.0 –10.0

Total United States 328.1 –18.8 177.8 –25.6 57.9 –11.4

Note: (—) = data not available.

Coronary Heart Disease

New and Hospital

Total 13,000,000 7,100,000 1,200,000 865,000 494,382 179,514 2,125,000 $142.1

• Among Americans ages 40–74, NHANES data found the

Per 1,000 Persons

1200 among women than men. Increases in the prevalence of AP

(ICD/9 413) (ICD/10 I20)

Note: Angina pectoris is chest pain or discomfort due to insufficient

Per 1,000 Persons

5 hypertension vary substantially. (NHANES III [1988–94],

(CHS, NHLBI, Arch Intern Med 2002;162:2325–32) 50 45.0 1999–02

Source: CDC/NCHS . Data based on a single measure of blood pressure.

Type of Presentation Rate per 1,000 Live Births Number

— 80 percent of men and 70 percent of women under age 2 1.8

Bacterial Endocarditis Total females 2,501 (69.9%)* 33,000

Note: (–) = data not available.

Cigarette Smoking, Overall Prevalence

Note:(—) = data not available; NR = data considered unreliable.

• Direct medical costs and lost productivity costs associated

• Among children and adolescents ages 4–19, the mean total

9 percent), and divorced or separated adults (29.1 percent)

BMI <25 BMI 25-29.9 BMI 30+

Note: BMI indicates body mass index: weight in kilograms divided

Prevalence of Prevalence of Prevalence of

9 FHS showed a BMI increase around 3 kg/m2 raised the risk

• In 1998–99, surveys of people in 8 states and the District of Non-Hispanic Whites

Note: Obesity is defined as a BMI of 30.0 or higher.

• Data from the NHANES (1999–2000) study of the

Risk Non-Hispanic Whites

— An estimated 49–69 million adults in the United States Blacks

• In 2002, the direct and indirect cost of diabetes was $132

* Findings for men are similar but of lower magnitude. See:

Deaths/1,000 Person Years

The Institute of Medicine defines quality of care as “the

Acute myocardial infarction Percent of inpatients Heart failure Percent of inpatients

Aspirin within 24 hours of admission 85% Documentation of LVEF 99%

Stroke Percent of inpatients

National Acute Coronary

* Excluding patients with contraindications to these therapies

2,500 2,363 2,199

Note: (–) = data not available.

Trends in Cardiovascular Operations and Procedures

PTCA Endarterectomy Pacemakers

Note: (–) = data not available.

Diseases and Total Total White Black Mexican-American